LAUSR

Laparoscopic cholecystectomy is generally accepted as the gold standard treatment for symptomatic gallstones [1, 2]. For patients who are not suitable operative candidates, endoscopic ultrasound (EUS)-guided cholecystoduodenostomy or cholecystogastrostomy can be performed using a double-flanged, fully covered, metal stent as a bridge to further transduodenal or transgastric cholecystolithotomy [3, 4]. Given that the diameter of the stent is limited, it was previously believed that only gallstones of less than 1 cm in diameter should be removed by this novel technique. Here, we report a patient with a symptomatic gallstone larger than 1 cm who successfully underwent endoscopic transduodenal cholecystolithotripsy via a double-flanged, fully covered, metal stent. An 80-year-old woman was admitted to the medical center with chills, fever, and nausea for 17 days, as well as jaundice for 7 days. An initial contrast computed tomography (CT) scan and transabdominal ultrasound revealed gallbladder and common bile duct (CBD) stones (▶Fig. 1). Further EUS demonstrated that the stone in the gallbladder was approximately 20×16mm in size, and the stones in the CBD were 4–7mm in diameter (▶Fig. 2 a, b). As the poor medical condition of this patient made her an unsuitable operative candidate, endoscopic sphincterectomy and EUS-guided cholecystolithotomy were planned to treat the cholelithiasis and choledocholithiasis. After informed consent had been obtained, the EUS-guided cholecystoduodenostomy was carried out using a previously reported technique [4, 5]. A longitudinal echoendoscope with a working channel of 3.8mm was introduced into the duodenum to scan for and mark the puncture point. An EchoTip Ultra EUS needle (22G; Cook Medical Inc., Bloomington, Indiana, USA) was introduced via the working channel of the echoendoscope, and the gallbladder was punctured under EUS guidance. Bile was aspirated, and 10mL of radiographic contrast was injected to confirm that the punctured structure was the gallbladder. Under the guidance of EUS and fluoroscopy, the double-flanged stent (2.5 cm in length, 1.5 cm in width, 1.2 cm in diameter) was placed and deployed as a bridge between the gallbladder and the duodenum. Next, endoscopic sphincterectomy was performed, which successfully removed the stones from the CBD. E-Videos