Endoscopic ultrasound-guided gallbladder drainage as a second option of biliary decompression after failed endoscopic retrograde cholangiopancreatography for the management of malignant distal biliary obstruction.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is recommended as a rescue treatment of malignant distal biliary obstruction (MBDO) after failed ERCP and endoscopic ultrasound-guided biliary drainage (EUS-BD). A 64-year-old male was admitted for painless obstructive jaundice and anemia. For religious reasons, he refused any blood transfusions. Abdominal computed tomography scan showed a pancreatic tumor with dilation biliary tree and liver metastasis. ERCP failed and advanced biliary cannulation technique such as precut were avoided due to a high risk of bleeding. We avoided the two transmural EUS-BD approaches, which include EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy, due to smaller targets and considered riskier in this patient. Since the gallbladder was markedly distended and the cystic duct was patent, we performed a cholecystogastrostomy with a 15x10 mm electrocautery lumen-apposing metal stent (EC-LAMS) as a second option of biliary drainage. After a week, the serum bilirubin levels decreased to normal values and the patient was uneventfully discharged. At follow-up, he refused to receive chemotherapy and died six months later due to cancer progression.