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Digital cholangioscopy-assisted endoscopic gallbladder drainage

      Percutaneous cholecystostomy tube (PTC) placement has been the mainstay of therapy for patients with acute and chronic cholecystitis who are poor candidates for surgery. PTC is limited by catheter-related adverse events, postprocedure pain, and recurrence of cholecystitis. Alternatively, endoscopic gallbladder drainage (EGBD) by the placement of a plastic transcystic stent during ERCP has been shown to be effective. Comparative studies have shown EGBD to have fewer adverse events, lower pain scores, and less recurrence of cholecystitis compared with PTC. However, the technical success rates of EGBD range from 79.3% to 100% because of the challenges of maneuvering a wire across a potentially small, occluded, and tortuous cystic duct. Digital cholangioscopy may help overcome these challenges to locate and traverse the cystic duct. An elderly patient who was a poor surgical candidate with recurrent cholecystitis underwent successful EGBD by means of cholangioscopy-directed placement of a transcystic wire into the gallbladder (Video 1, available online at www.giejournal.org). The cystic duct could not be opacified by conventional cholangiography because of occlusion with sludge and pus. Direct visualization and irrigation with the digital cholangioscope facilitated opening of the cystic duct and wire passage into the gallbladder for stent placement (Fig. 1). Digital cholangioscopy is a useful tool that can increase the technical success of EGBD.
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      Figure 1Direct visualization of the cystic duct with pus being suctioned through the cholangioscope.
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