Case series demonstrates effective gallbladder drainage in patients with Billroth II anatomy using a novel technique, indicating its utility for challenging cases.
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an established minimally invasive treatment for acute cholecystitis in patients unfit for surgery.[ 1 ] However, duodenal access with a conventional oblique-viewing echoendoscope can be challenging in patients with Billroth II anatomy. Several reports have described the use of a forward-viewing echoendoscope to overcome this limitation.[ 2 ] [ 3 ] Here, we present a nasobiliary catheter landmark technique that enables EUS-GBD using a conventional oblique-viewing echoendoscope in patients with Billroth II anatomy. An 82-year-old woman with a history of subtotal gastrectomy with Billroth II reconstruction for gastric cancer presented with acute cholecystitis. Magnetic resonance cholangiopancreatography demonstrated marked gallbladder distension and wall thickening ([ Fig. 1 ]). Because repeat surgery was considered high risk, EUS-GBD was planned. Fig. 1 Magnetic resonance cholangiopancreatography demonstrating marked gallbladder distension and wall thickening consistent with acute cholecystitis. A pediatric colonoscope (PCF-H290; Olympus, Tokyo, Japan) was advanced through the gastrojejunostomy into the afferent limb and duodenum. A 5-Fr nasobiliary catheter (A-Drain; A&A M.D., Seongnam-si, Korea) was advanced deeply into the duodenum, and the colonoscope was withdrawn. A linear echoendoscope (GF-UCT260; Olympus, Tokyo, Japan) was advanced toward the duodenum using the nasobiliary catheter as an endoscopic landmark ([ Fig. 2 ]). After visualization of a markedly distended gallbladder on EUS, EUS-GBD was performed using a 15×10 mm cautery-enhanced lumen-apposing metal stent (HOT AXIOS; Boston Scientific, Marlborough, Massachusetts, USA; [ Fig. 3 ]; [ Video 1 ]). Four weeks later, peroral cholecystoscopy demonstrated complete gallstone clearance, and the lumen-apposing metal stent was exchanged for a double-pigtail plastic stent ([ Fig. 4 ]). Eight-month follow-up computed tomography demonstrated the plastic stent in situ without recurrent cholecystitis ([ Fig. 5 ]). Fig. 2 A nasobiliary catheter landmark technique for duodenal access. ( a ) A 5-Fr nasobiliary catheter is advanced deeply into the duodenum and left in situ after the withdrawal of the pediatric colonoscope. ( b ) A linear echoendoscope is advanced toward the duodenum using the nasobiliary catheter as an endoscopic landmark. Fig. 3 EUS-guided gallbladder drainage using a cautery-enhanced lumen-apposing metal stent. ( a ) An endoscopic ultrasound image showing a markedly distended gallbladder. ( b ) A fluoroscopic image demonstrating the successful deployment of the lumen-apposing metal stent. Video 1 A nasobiliary catheter landmark technique for endoscopic ultrasound-guided gallbladder drainage using a conventional oblique-viewing echoendoscope in a patient with Billroth II anatomy. Download Video Fig. 4 Peroral cholecystoscopy performed 4 weeks after EUS-guided gallbladder drainage. ( a ) Complete gallstone clearance is confirmed. ( b ) The lumen-apposing metal stent is exchanged for a double-pigtail plastic stent. Fig. 5 Eight-month follow-up computed tomography demonstrating the double-pigtail plastic stent in situ without recurrent cholecystitis. Using this technique, EUS-GBD was successfully performed in five consecutive patients with Billroth II anatomy ([ Table 1 ]). The nasobiliary catheter landmark technique may facilitate EUS-guided GBD using a conventional oblique-viewing echoendoscope in patients with Billroth II anatomy. Table 1 Clinical characteristics and procedural outcomes of five patients undergoing EUS-guided gallbladder drainage using the nasobiliary catheter landmark technique Patient Age/sex PCF insertion-withdrawal time (min) Echoendoscope insertion-LAMS deployment time (min) Total procedure time (min) Adverse events Follow-up duration (mo) 1 82/F 9 13 22 No 15 2 82/M 8 4 12 No 9 3 87/M 14 9 23 No 10 4 86/M 9 11 20 No 7 5 95/M 9 12 21 No 1 Abbreviations: EUS, endoscopic ultrasound; LAMS, lumen-apposing metal stent; PCF, pediatric colonoscope. Note: Technical success and clinical success were achieved in all five patients. Endoscopy_UCTN_Code_TTT_1AS_2AK Publication History Received: 16 June 2026 Accepted after revision: 11 July 2026 Article published online: 29 July 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany
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