Single-balloon enteroscope-bridged endosonography-guided gallbladder drainage with lumen-apposing metal stent in Billroth II

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) effectively treats acute cholecystitis (ACC) in patients unsuitable for cholecystectomy.[ 1​ ] However, advancing an oblique-viewing echoendoscope (OVE) through the afferent limb in Billroth II anatomy is challenging. Prior approaches include forward-viewing echoendoscopes [ 2​ ] [ 3​ ] [ ​4​ ] or multi-step LAMS deployment with anchoring stents.[ 5​ ] We describe a single-balloon enteroscope (SBE)-bridged approach enabling one-step LAMS deployment with a conventional OVE. An 88-year-old man with severe frailty (Clinical Frailty Scale 7, American Society of Anesthesiologists Physical Status 3, Charlson Comorbidity Index 8) with Billroth II anatomy after distal gastrectomy presented with ACC ([ Fig. 1 ]). Given his prohibitive surgical risk and limited life expectancy, EUS-GBD with long-term LAMS placement was selected. Fig. 1 Pre-procedure computed tomography demonstrating acute cholecystitis in a patient with Billroth II anatomy following distal gastrectomy. ( a ) An axial image showing a markedly distended gallbladder with wall thickening and pericholecystic fat stranding. ( b ) A coronal image confirming the markedly distended gallbladder along its longitudinal axis. A short-type SBE (SIF-H290S; Olympus) with an overtube was advanced through the afferent limb to the blind end near the duodenal bulb, where a 0.035-inch guidewire was placed. After SBE withdrawal, an OVE (GF-UCT260; Olympus) was advanced over the guidewire into the duodenum. Awareness of the rigid distal-tip length facilitated passage through the gastrojejunostomy outlet and angulation near the ligament of Treitz, achieving a position comparable to that in normal anatomy ([ Fig. 2 ]). EUS demonstrated a markedly distended gallbladder. A 10-mm electrocautery-enhanced LAMS (Hot AXIOS; Boston Scientific) was deployed between the duodenal bulb and the gallbladder using a single-step freehand technique. The SBE and OVE insertion required 10 and 20 minutes, respectively; LAMS deployment took 1 minute, and the total procedure time was 46 minutes. Immediate purulent bile drainage was achieved, and ACC resolved without adverse events ([ Fig. 3 ]). At 2 months, the LAMS remained patent; stent exchange was deferred due to patient frailty, and surveillance continued ([ Fig. 4 ]; [ Video 1 ]). Fig. 2 Single-balloon enteroscope (SBE)-bridged insertion of an oblique-viewing echoendoscope (OVE) in the Billroth II anatomy. Two sharp angulations were identified along the retrograde afferent-limb pathway: at the gastrojejunostomy outlet (white arrows) and near the ligament of Treitz at the duodenojejunal flexure (black arrows). ( a and b ) Fluoroscopic images during SBE (SIF-H290S; Olympus) insertion showing the successful traversal of the two angulations. ( c ) After SBE withdrawal, the 0.035-inch guidewire remained in situ across the entire afferent limb, serving as a bridge for scope exchange. ( d and e ) The OVE (GF-UCT260; Olympus) was advanced over the guidewire and traversed the gastrojejunostomy ( d ) and Treitz ligament ( e ) angulations. ( f ) The final OVE position at the duodenal bulb with a stable scope configuration comparable to that in the normal anatomy. Fig. 3 Endoscopic ultrasound-guided gallbladder drainage with one-step lumen-apposing metal stent (LAMS) deployment. ( a ) Endosonographic visualization of the markedly distended gallbladder (>40 mm) from the duodenal bulb. ( b ) Deployment of the distal flange of a 10-mm electrocautery-enhanced LAMS (Hot AXIOS; Boston Scientific) within the gallbladder under endosonographic guidance. ( c ) A post-deployment fluoroscopic image showing the LAMS connecting the duodenal bulb and the gallbladder. ( d ) An endoscopic view showing copious purulent bile draining through the LAMS into the duodenal lumen. Fig 4 Computed tomography after endoscopic ultrasound-guided gallbladder drainage. ( a ) Computed tomography immediately after the procedure showing decompression of the gallbladder with the lumen-apposing metal stent (LAMS). ( b ) Follow-up computed tomography at 2 months demonstrating a persistently patent LAMS with sustained gallbladder decompression and no signs of stent migration, occlusion, or other complications. Video 1 Single-balloon enteroscope-bridged endosonography-guided gallbladder drainage with a lumen-apposing metal stent in the Billroth II anatomy. Download Video To our knowledge, this is the first report of SBE-guided OVE insertion enabling one-step LAMS-based EUS-GBD, providing an alternative to using forward-viewing equipment. Endoscopy_UCTN_Code_TTT_1AS_2AK Publication History Received: 06 June 2026 Accepted after revision: 06 July 2026 Article published online: 16 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