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Cholecystectomy is the standard therapy for patients with acute cholecystitis. However, EUS-guided gallbladder drainage (EUS-GBD) is an endoscopic technique shown to be a technically feasible option for patients, especially those deemed too high risk for surgical options because of comorbidities or level of illness.
Case Description
A 54-year-old woman with COVID-19 in 2021, complicated by chronic systolic heart failure (ejection fraction 30%) requiring biventricular pacemaker/defibrillator, hypertension, history of intentional lye ingestion in 2002 resulting in gastric perforation requiring Billroth II gastrojejunostomy, and more than 20 esophageal dilations for recurrent strictures, presented with 1 day of biliary colic. At presentation, vitals were normal with the examination demonstrating right upper quadrant abdominal tenderness and a positive Murphy sign. Total bilirubin was normal; alkaline phosphatase was elevated to 146 IU/lt; aspartate aminotransferase was 216 IU/lt; and alanine aminotransferase was 298. An abdominal US demonstrated a distended gallbladder and gallstones without biliary duct dilatation or choledocholithiasis (Fig. 1).
Because of high surgical risk and the desire to avoid percutaneous drainage, the patient opted for EUS-GBD following an ERCP. An enteroscopy was performed to identify the afferent enteral limb. After inadvertent pancreatic duct cannulation, a 4F × 4-cm single-pigtailed stent was placed into the pancreatic duct. The bile duct was then easily cannulated, revealing a patent cystic duct and normal main bile duct without dilatation, stenosis, or stones (Fig. 2).
Figure 2ERCP with cholangiogram and pancreatic duct stent.
The therapeutic echoendoscope was then used to successfully perform an EUS-GBD using a 15- × 10-mm lumen-apposing metal stent (LAMS), anchored with a 10F × 3-cm double-pigtailed plastic stent following dilation of the LAMS to 8 mm with a balloon dilation device (Video 1, available online at www.giejournal.org; Fig. 3).
Figure 3Fluoroscopic image of successful cholecystoenterostomy.
The patient did well without any adverse events. A postprocedural CT scan was performed on postprocedure day 3 and showed no obvious intra-abdominal adverse event (Fig. 4). A follow-up endoscopy was performed 8 weeks after LAMS placement for removal of the double-pigtailed stent and LAMS (Fig. 5) and for placement of three 7F × 7-cm double-pigtailed plastic stents to maintain indefinite patency of the cholecystoenteric fistula (Fig. 6).
Figure 4AXIOS (Boston Scientific, Marlborough, Mass, USA) and double-pigtailed stent appearance on a CT scan (axial image).
EUS-GBD is a technically feasible and clinically useful approach for treatment of acute cholecystitis even in patients with Billroth II gastrojejunostomy anatomy.
Disclosure
Dr Villa is a consultant for Medtronic plc, Noah Medical Inc, and Olympus Corp. All other authors disclosed no financial relationships.
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