Endoscopic closure of gallbladder perforation

A 55-year-old woman with primary sclerosing cholangitis, decompensated cirrhosis, and metastatic cholangiocarcinoma presented with abdominal pain, worsening ascites, and secondary fungal peritonitis. Ascitic fluid was green in color with an elevated neutrophil count (8903/mm³) and bilirubin concentration (9.2 mg/dL), suggesting a bile leak. Magnetic resonance imaging showed a markedly distended gallbladder with a small perforation. The patient was not a surgical candidate, given decompensated cirrhosis, and infrared-guided percutaneous drainage was not an option, given moderate ascites. She had a recent ERCP with placement of a biliary metal stent for cholangiocarcinoma precluding endoscopic cystic duct stenting. EUS showed a markedly distended gallbladder, and an EUS-guided cholecystoduodenostomy with a lumen-apposing, fully covered metal stent was performed to obtain endoscopic access to her gallbladder. Through the cholecystoduodenostomy, endoscopic closure of the gallbladder perforation was performed using 5 endoscopic clips (Video 1, available online at www.giejournal.org). To seal the repair, we injected 2 mL of cyanoacrylate glue in the vicinity of the clips (Fig. 1). Repeat paracentesis showed reduction in the neutrophil count (838/mm³) and fluid bilirubin concentration (3.2 mg/dL). The patient had rapid clinical improvement and was discharged 2 days later. She continued to be asymptomatic at an 8-week follow-up with no worsening of ascites. In conclusion, EUS-guided cholecystoduodenostomy with a lumen-apposing stent provides the opportunity for endoluminal gallbladder therapy such as endoscopic closure of perforation and removal of gallbladder polyps and stones.