SINGLE-STEP ERCP PLUS EUS-GUIDED GALLBLADDER DRAINAGE THROUGH LAMS FOR CHOLECYSTOLITHIASIS WITH ACUTE CHOLECYSTITIS AND CONCOMITANT CHOLEDOCHOLITHIASIS, IN PATIENTS UNFIT FOR SURGERY

Aims Endoscopic retrograde cholangiopancreatography (ERCP), followed by laparoscopic cholecystectomy, remains the gold standard for the management of cholecysto-choledocholithiasis. Laparo-endoscopic rendezvous, which combines laparoscopic cholecystectomy and ERCP at the same time, is an alternative. Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using lumen apposing metal stents (LAMS) has been increasingly used. Furthermore, a novel dedicated fully-covered and electrocautery-enhanced LAMS (Hot Axios^TM; Boston Scientific, USA) has been developed. This study aimes to evaluate the effectiveness and safety of single-step ERCP plus EUS-GBD through LAMS for cholecysto-choledocholithiasis with acute cholecystitis in patients unfit for surgery.

Methods Thirteen patients unfit for surgery (5 women, mean age 84.6±7.3 years), who presenting cholecysto-choledocholithiasis with acute cholecystitis, were consecutively enrolled. All patients underwent ERCP plus EUS-GBD through LAMS in a single-step, over a six-month period (May-October 2019). First, an ERCP was performed for common bile duct stones´ removal. Immediately after, an EUS-guided cholecystogastrostomy or a cholecystoduodenostomy was performed using the Hot Axios^TM system. Primary outcomes were technical and clinical success. We also recorded the adverse events rate and stent patency.

Results The median procedure time was 40 minutes (range 28-52). The technical and the clinical success was obtained in all patients, and stent patency was good in all of them (using 10x10mm or 15x10mm LAMS). LAMS was removed four weeks after placement, in patients with good life expectancy, otherwise it was left indefinitely. Starting from LAMS’ placement, the median follow-up time was 105 days (range 32-178) assessed by abdomen computer tomography (CT-scan), without complications during follow-up. No complications as “buried stent” were observed at the moment of LAMS’ removal.

Conclusions Single-step management of cholecysto-choledocholithiasis with acute cholecystitis, performed with ERCP plus EUS-GBD through LAMS, has high technical and clinical success rates and shows very low complications and reintervention rates in patients unfit for surgery, that are best candidates. Further studies are needed.