LAUSR

A 75-year-old man was admitted with right hypochondralgia and high fever due to cholecystitis, concomitant with unresectable cholangiocarcinoma. He had undergone endoscopic partial stentin-stent (PSIS) placement of triple selfexpandable metal stents (SEMSs) for jaundice due to a Bismuth type IV malignant hilar biliary stricture 11 months previously [1], and placement of plastic stents within the SEMSs for recurrent biliary obstruction 2 months previously, using a short double-balloon enteroscope (DBE; EI-B530, Fujifilm, Tokyo). Percutaneous transhepatic gallbladder drainage (PTGBD) was performed for treatment of his cholecystitis, and his condition improved immediately (▶Fig. 1 a). However, permanent gallbladder drainage was required because recurrent cholecystitis occurred without ongoing PTGBD. Accordingly, endoscopic gallbladder stenting (EGS) was attempted via the papilla of Vater using a short DBE, but insertion of the guidewire into the gallbladder through the SEMSs was difficult. A 0.025-inch guidewire (Visiglide 2; Olympus, Tokyo, Japan) was however successfully inserted via the percutaneous route from the gallbladder through the SEMSs and into the duodenum. Following advancement of a short DBE to the papilla of Vater, the guidewire was firmly grasped with a snare (Captivator II; Boston Scientific, Natick, Massachusetts, USA) and withdrawn through the DBE. EGS was accomplished by the guidewire being exchanged with a 0.035-inch guidewire (Revowave; Olympus), which was inserted from the endoscope side to the outside of the body, using a 5.5-Fr catheter (PR-V234Q; Olympus) (▶Fig. 1 b). Following this, it was possible to advance a 7-Fr pig-tailed stent (Gaderius, Tokyo, Japan) through the SEMSs into the gallbladder while fixing both ends of the guidewire (▶Fig. 1 c). The stent was then successfully placed after the tip of the guidewire had been released (▶Fig. 1d; ▶Video1). PTGBDwas not required again and the patient experienced no further recurrent cholecystitis before his death 5 months later. EGS using a rendezvous technique for cholecystitis after SEMS placement was useful in this patient because it facilitated insertion of both the guidewire and the stent across the interstices of the SEMSs.