The Tokyo Guideline 18 states that drainage, including percutaneous, transpapillary, or transmural approaches, should be considered for fragile patients with moderate acute cholecystitis [1] [2]. With transmural endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), cutting-edge electrocautery-enhanced lumen-apposing metal stents (LAMSs) are key devices in certain regions [3]. However, a double-pigtail plastic stent (DPPS) is still used in areas where LAMSs are inapplicable [4]. Previous unicolored DPPSs had a positioning marker; however, physicians hesitate to move the stent in either direction if this marker is not in the endoscopic view. Recently, a bicolored DPPS has emerged to facilitate appropriate stent positioning in the endoscopic view.

An 80-year-old woman with mild right-sided hemiparesis caused by previous cerebral infarction was admitted with grade II acute cholecystitis ([Fig. 1]). Her American Society of Anesthesiologists physical status and adjusted Charlson Comorbidity Index scores were 3 and 6, respectively [2]. Therefore, urgent surgery was avoided and the patient underwent EUS-GBD ([Video 1]) after a multidisciplinary discussion.

Endoscopic ultrasound-guided transduodenal gallbladder puncture using a 19-gauge lancet-shaped needle was followed by 0.025-inch guidewire placement and fistula dilation using an electrocautery-enhanced dilator. Next, we advanced a bicolored DPPS made of polyethylene and nylon comprising an inner sheath (Piglet, 7F, 4 cm; Olympus Medical, Tokyo, Japan) under endoscopic visualization of a yellow-to-black demarcation ([Fig. 2]). Finally, we deployed the DPPS ([Fig. 3]) after aspiration/irrigation of the infected bile without complications [5].