Introduction

Lumen-apposing metal stents have increasingly been used for acute cholecystitis cases where surgery is not an option. However, endoscopic ultrasound gallbladder drainage (EUS-GBD) is rarely performed in cases where surgery can be safely planned. One reason for this is the large size of the fistula and the spread of inflammation to the cystic duct, which makes surgery difficult. Preoperative EUS-GBD has the potential to reduce hospital stay, alleviate pain, and eliminate the need for external drainage tube management when compared to percutaneous drainage. To address these challenges, we developed a novel drainage kit specifically for EUS-GBD. This kit includes an anchor to fix the gallbladder and gastric walls and a thin drainage tube that allows one-step insertion and washing. This kit is believed to help create a smaller fistula, prevent the spread of inflammation to the cystic duct, and facilitate subsequent surgery. Here, we present the preliminary results of an exploratory clinical study using this novel kit as a first-in-human case.

Aims & Methods

The aim of this study was to evaluate the clinical outcomes of preoperative EUS-GBD using a novel drainage kit.
Between April 2024 and January 2025, EUS-GBD was performed using the novel drainage kit in six cases of acute cholecystitis. These patients were eligible for elective surgery but ineligible for emergency surgery. There were five female patients with a mean age of 70.0 years (range: 55 to 88 years). The mean time from symptom onset to treatment was 2.7 days (range: 1 to 5 days). All patients had gallstones. All cases have undergone laparoscopic cholecystectomy (LapC) at a mean of 36.8 days (range: 32 to 43 days) after EUS-GBD. The technical success rate, clinical success rate, adverse event rate, mean hospital stay, and conversion rate to open surgery were evaluated.

Results

The technical success rate was 100%, and the clinical success rate was also 100%. No adverse events or open surgery occurred. The mean hospital stay after EUS-GBD was 5.3 days (range: 5 to 6 days), and the mean hospital stay after LapC was 5.3 days (range: 5 to 6 days).

Conclusion

Preoperative EUS-GBD using the novel drainage kit was feasible and safe.

Disclosure

Stock ownership: KOEDA Inc.

Clinical Case Summary

Introduction: Cap polyposis is a rare benign inflammatory condition characterized by inflammatory polyps covered with a fibrinopurulent exudate. It is more commonly observed in women and the elderly, although it can present at any age. The disease typically affects the rectum and sigmoid colon. The most frequent symptoms include mucous diarrhea and rectal bleeding. It has been associated with mucosal prolapse due to altered intestinal motility, Helicobacter pylori infection, and even intestinal dysbiosis.
Endoscopy: A 46-year-old male with no relevant personal or family medical history presented with altered bowel habits, characterized by increased stool frequency, decreased consistency, and the presence of mucus and blood, along with tenesmus and urgency. H. pylori testing was negative. Colonoscopy revealed numerous sessile and pedunculated polyps with an inflammatory appearance distributed throughout the colon, predominantly in the sigmoid and rectum. Most polyps were covered at their apex by a fibrinopurulent exudate (Figures 1–4). The colonic mucosa adjacent to the polyps appeared normal. Multiple biopsies were taken, confirming inflammatory polyps. A first therapeutic colonoscopy was performed, during which multiple polyps consistent with cap polyps were resected (Figure 5). Additional sessions were scheduled to complete polyp resection. Furthermore, a molecular study was performed using next-generation sequencing (NGS) with a multigene panel including genes associated with polyposis, with negative results.
Conclusions: The clinical course of cap polyposis remains unclear. The need for and timing of colonoscopy should be individualized based on the number of polyps and symptom severity. Initial treatment should be conservative, focusing on resolving constipation and eradicating H. pylori. In cases with persistent symptoms, endoscopic resection of the lesions should be considered.

Clinical Case Summary

A 50-year-old man with known hypertension and hypothyroidism was recently diagnosed with AML. He presented with high-grade fever for one month. There were no gastrointestinal complaints, weight loss, or night sweats. Physical examination was unremarkable aside from fever (38.7°C); he was hemodynamically stable.
Initial labs revealed pancytopenia: hemoglobin 8.4 g/dL, WBC 1.2 × 10⁹/L, platelets 42 × 10⁹/L, and ANC 200/µL. Peripheral smear confirmed febrile neutropenia. He was started on intravenous broad-spectrum antibiotics. Due to persistent fever, a workup for occult infections was initiated. Blood and urine cultures were negative. Serum and BAL galactomannan were positive, suggesting possible invasive aspergillosis; liposomal amphotericin B was commenced.
Abdominal ultrasound revealed a bulky pancreas with heterogeneous echotexture. Contrast-enhanced CT showed a 2×3 cm heterogeneously enhancing lesion in the pancreatic tail. CA 19-9 was normal. EUS identified a hypoechoic.The main differentials considered included: Leukemic infiltration: due to AML background, Primary pancreatic malignancy: suggested by the imaging appearance, Invasive fungal infection: supported by positive galactomannan assays,Pancreatic tuberculosis: rare, but considered due to an endemic background.
FNAC showed granulomatous inflammation with caseation. GeneXpert MTB/RIF was positive for M. tuberculosis.
He was started on anti-tubercular therapy. Fever resolved within 10 days. Imaging at 3 months showed resolution of the mass. He completed a 6-month course uneventfully.
The presence of a discrete mass and lack of gastrointestinal symptoms complicated the diagnosis. FNAC with GeneXpert was key in confirming TB and ruling out other causes.

References

Pancreatic TB is a rare form of extrapulmonary tuberculosis, accounting for less than 5% of abdominal TB cases. It typically affects younger individuals and may be more prevalent in immunocompromised patients, including those with HIV or malignancy.

Clinically, pancreatic TB is a great mimicker. Common symptoms include fever, abdominal pain, weight loss, and night sweats. Jaundice may be seen if there is biliary involvement. Radiologically, it is difficult to distinguish from pancreatic cancer or pancreatitis. Masses may be solid or cystic and can involve any part of the pancreas.

EUS has emerged as a critical tool in evaluating pancreatic lesions. It allows for high-resolution imaging and real-time sampling via FNAC. Cytological examination may reveal granulomatous inflammation, although this is not pathognomonic. A definitive diagnosis often hinges on demonstration of acid-fast bacilli, culture, or PCR-based methods such as GeneXpert.

Our case highlights the importance of considering TB in the differential diagnosis of pancreatic masses, especially in endemic areas or immunocompromised patients. Early diagnosis via EUS-FNA and initiation of ATT can result in complete clinical and radiological recovery, sparing the patient from unnecessary surgical intervention.