Title:Endoscopic Radial Incision and Cutting for Intra-gallbladder Stenosis：The First Clinical Practice

Endoscopic Radial Incision and Cutting (ERIC) has been widely used in the management of benign gastrointestinal and anastomotic stricture [1,2]. However, there is no report of ERIC treating intra-gallbladder stenosis yet. Gallbladder stenosis may be encountered, in pace with the application of various methods for gallbladder-preserving managements. Herein, the stenosis was completely resolved via ERIC, thereby facilitating gallbladder stones removal afterwards.

A 28-year-old female presented with a several-year history of intermittent upper abdominal pain. The patient was diagnosed with gallstones, that cholangioresonance imaging revealed a gourd-shaped gallbladder containing multiple stones in both chambers (Figure 1a). Although cholecystectomy was recommended at the local hospital, she declined and was subsequently transferred to our department for gallbladder-preserving cholelithotomy via natural orifice transluminal endoscopic surgery (Video 1).

The procedure was initiated via a transrectal approach to access the abdominal cavity. A gourd-shaped gallbladder was identified (Figure 1b). Intraluminal examination revealed significant stenosis with cicatricial mucosal changes (Figure 1c). ERIC was then performed using an IT knife to incise the stricture, allowing adequate passage of the endoscope (Figure 1d). This was followed by complete removal of all distal stones. Following thorough irrigation of the gallbladder cavity, which confirmed the absence of residual calculi (Figure 1e), both the gallbladder and intestinal access sites were securely closed with endoclips. No intraoperative and postoperative adverse event was observed. On three-month follow-up, an abdominal computed tomography (CT) demonstrated significantly improvement in gallbladder morphology (Figure 1f). 

In this case, we demonstrate the feasibility and efficacy of ERIC for treating intra-gallbladder stenosis. Moreover, ERIC resolved intra-gallbladder stenosis, consequently reducing the recurrence of gallstones. This study highlights the potential for further exploration and application in similar cases.