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EUS-guided gallbladder drainage (EUS-GBD) is a well-described alternative to percutaneous gallbladder drainage for management of acute cholecystitis in patients who are poor surgical candidates.
Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.
Over the past several years, the technique has evolved from the initial use of plastic stents and self-expanding metal stents to the current use of lumen-apposing metal stents (LAMSs).
EUS-guided gallbladder drainage and subsequent peroral endoscopic cholecystolithotomy: a tool to reduce chemotherapy discontinuation in neoplastic patients?.
We present a case of EUS-GBD and electrohydraulic lithotripsy (EHL) in a patient with stump cholecystitis.
Case Report
A 31-year-old woman presented with right-upper-quadrant pain and imaging findings of acute cholecystitis. She underwent a laparoscopic cholecystectomy, which was converted to an open procedure because of extensive adhesive disease involving the gallbladder. Owing to the inflammation and gallbladder adhesion to multiple organs, the decision was made to perform a subtotal cholecystectomy. The patient initially did well postoperatively but started having intermittent recurrence of symptoms after 1 month. Six months postoperatively, she presented to the hospital with an acute flare of epigastric abdominal pain. A CT scan of her abdomen showed a thickened remnant gallbladder wall with a retained gallstone, concerning for stump cholecystitis (Fig. 1). The patient was evaluated by the surgical team, but given the prior difficulty of her surgery and extensive inflammation, she was referred to gastroenterology for endoscopic management (Video 1, available online at www.giejournal.org).
Figure 1A CT scan of the abdomen showing a thickened remnant gallbladder wall with a retained stone (blue arrow).
Using a linear echoendoscope, we identified the remnant gallbladder from the duodenal bulb and punctured with a 22-gauge FNA needle (Fig. 2). Dilute contrast mixed with methylene blue was injected through the FNA needle to achieve gallbladder distension. On fluoroscopy, the remnant gallbladder with the retained stone was visualized (Fig. 3). An 8- × 8-mm electrocautery enhanced LAMS was directly deployed in the gallbladder lumen via a transduodenal approach. The stent was subsequently dilated to 8 mm using a wire-guided balloon and a 7F × 4-cm double-pigtail (DPT) stent was placed across the LAMS in the gallbladder (Fig. 4). A CT scan was obtained the following day and confirmed appropriate positioning of the stents. The patient was discharged home and scheduled for a cholecystoscopy and EHL in 6 weeks.
Figure 2EUS-guided puncture of the remnant gallbladder with a 22-gauge FNA needle (blue arrow).
Figure 4Fluoroscopic image showing successful transduodenal drainage of gallbladder stump using a lumen-apposing metal stent and a double-pigtail stent.
On follow-up endoscopy, the DPT stent was removed. Using the slim endoscope, we performed a direct peroral cholecystoscopy. A large stone was visualized in the remnant gallbladder (Fig. 5). The LAMS was removed using rat-tooth forceps, and the cholecystoduodenostomy tract was dilated to 12 mm using a wire-guided balloon (Fig. 6). The endoscope was then advanced in the remnant gallbladder, and an EHL probe was placed adjacent to the stone (Fig. 7). Sequential pulses of electrohydraulic lithotripsy were delivered using a power of 100 W until the stone was fragmented. The stone fragments were removed using a snare (Fig. 8). This process was repeated multiple times until all the stone fragments were cleared. Final inspection on direct cholecystoscopy showed no retained stones in the gallbladder remnant (Fig. 9). A 7F × 4-cm DPT stent was placed transduodenally in the remnant gallbladder. The patient was discharged the same day without any adverse events. At a 4-week follow-up in clinic she had continued to do well without any recurrence of symptoms. Her DPT stent was removed at 3 months. At her 7-month follow-up, she was doing well with no complaints.
Figure 5Endoscopic image showing the stone in the remnant gallbladder on cholecystoscopy.
Figure 6Fluoroscopic image showing balloon dilation of the cholecystoduodenostomy tract after removal of lumen-apposing metal stent and double-pigtail stent.
Off-label use of LAMS for EUS-GBD has evolved as an accepted management of cholecystitis in patients who are poor surgical candidates. Traditionally, these drainages have been performed using a larger diameter LAMS of 10 or 15 mm. The availability of smaller-diameter LAMSs has enabled endoscopic interventions in confined spaces with limited surgical accessibility.
Disclosure
Dr Pawa is a consultant for Boston Scientific. Dr Campbell disclosed no financial relationships.
Definitive nonsurgical management of stump cholecystitis with EUS-guided lumen-apposing metal stent placement and electrohydraulic lithotripsy.
References
Luk S.W.
Irani S.
Krishnamoorthi R.
et al.
Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.
EUS-guided gallbladder drainage and subsequent peroral endoscopic cholecystolithotomy: a tool to reduce chemotherapy discontinuation in neoplastic patients?.
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