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We thank Dr Nakai and his colleagues for their great interest in and valuable comments to our article.1Imai H, Kitano M, Omoto S, et al. EUS-guided gallbladder drainage for rescue treatment of malignant distal biliary obstruction after unsuccessful ERCP. Gastrointest Endosc. In Press 2016.Google Scholar They discussed the utility of observing the cystic duct before carrying out EUS-guided gallbladder drainage (EUS-GBD). We agree that the indications for EUS-GBD are limited because this procedure can be performed only in cases in which cystic duct takeoff is not involved. Therefore, evaluating cystic duct patency before EUS-GBD is important. Intraductal ultrasonography (IDUS) is the most suitable tool to check cystic duct patency during ERCP, by which tumor involvement of the cystic duct is accurately confirmed.2Isayama H. Kawabe T. Nakai Y. et al.Cholecystitis after metallic stent placement in patients with malignant distal biliary obstruction.Clin Gastroenterol Hepatol. 2006; 4: 1148-1153Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar However, it was impossible to use IDUS for confirmation of cystic duct patency before EUS-GBD, because all patients underwent EUS-GBD after ERCP failed in our study.1Imai H, Kitano M, Omoto S, et al. EUS-guided gallbladder drainage for rescue treatment of malignant distal biliary obstruction after unsuccessful ERCP. Gastrointest Endosc. In Press 2016.Google Scholar Thus, cystic duct patency was confirmed by EUS before EUS-GBD was performed in all 12 patients.1Imai H, Kitano M, Omoto S, et al. EUS-guided gallbladder drainage for rescue treatment of malignant distal biliary obstruction after unsuccessful ERCP. Gastrointest Endosc. In Press 2016.Google Scholar When the cystic duct was entrapped by the tumor, we did not carry out EUS-GBD. In conclusion, cystic duct patency should be confirmed by EUS before EUS-GBD is performed. If the cystic duct is obstructed by tumor involvement, EUS-guided bile duct drainage or percutaneous transhepatic bile duct drainage rather than EUS-GBD should be used. All authors disclosed no financial relationships relevant to this publication. Cystic duct patency in EUS-guided gallbladder drainage as a rescue treatment for malignant biliary obstructionGastrointestinal EndoscopyVol. 83Issue 6PreviewWe read with great interest the article by Imai et al1 on EUS-guided gallbladder drainage (EUS-GBD) as an alternative biliary drainage for malignant biliary obstruction (MBO). The authors reported a high rate of technical success with acceptable adverse events using EUS-GBD as a rescue technique. As the authors claimed, a distended gallbladder is a good target for puncture, but we are concerned about the indications for EUS-GBD because we believe that cystic duct patency is essential for EUS-GBD in this setting. Full-Text PDF