Transduodenal necrosectomy for acute cholecystitis with the use of a novel single-operator cholangioscope

Recently, a digital, catheter-based, single-operator cholangiopancreatoscope (SPYGlass DS Direct Visualization System; SPY DS, Boston Scientific, Natick, Mass) has become available. Herein, technical tips for transduodenal necrosectomy in acute cholecystitis with the use of a novel single-operator cholangioscope are presented. An 84-year-old-man was admitted because of abdominal pain. On CT, he received a diagnosis of acute cholecystitis. Because he had severe interstitial pneumonia and was at risk for removing a tube because of mild dementia, EUS gallbladder drainage (EUS-GBD) was selected as an alternative treatment and was successfully performed without any adverse events (Fig. 1A). After EUS-GBD, the patient’s clinical symptoms and laboratory results improved. However, 1 week later, fever and increased inflammatory markers were seen. First, an ERCP catheter was inserted into the EUS-GBD stent, followed by guidewire insertion. Next, the single-operator cholangiopancreatoscope was inserted into the EUS-GBD stent under guidewire guidance (Fig. 1B). Massive necrotic tissue was then seen in the gallbladder. Cleaning was performed with water injection combined with an injector system and suction, and necrosectomy was performed with the forceps biopsy device of a single-operator cholangiopancreatoscope (Fig. 1C; Video 1, available online at www.giejournal.org). This novel single-operator cholangiopancreatoscope has a clinical impact not only on diagnosis or target biopsy by direct visualization but also on various interventional treatments such as necrosectomy.