Symptomatic cholelithiasis and acute cholecystitis treated by EUS-guided gallbladder drainage with gallbladder toilette

An 81-year-old woman with a history of colorectal cancer, connective tissue disease, previous dorsal spine stabilization, and late mild cognitive impairment was admitted to our emergency department with abdominal pain, fever, and jaundice. She had experienced recurrent upper right abdominal pain for the past 2 years and had been diagnosed with cholelithiasis. Laboratory findings showed leukocytosis, elevated C-reactive protein levels, elevated alkaline phosphatase, and hyperbilirubinemia. A computed tomography (CT) scan revealed gallbladder distention and wall thickening with pericholecystic fluid and a 25-mm gallstone impacted in the infundibulum.

Because of her age and comorbidities, the patient was at high risk for surgery. After joint discussion, we decided on an endoscopic ultrasound (EUS)-guided gallbladder drainage with placement of an electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) (10 × 20-mm Hot-Spaxus; Taewoong Medical Co., Gimpo, Korea) [1] [2]. The cholecystogastrostomy was successfully performed using the freehand technique and intrachannel release of the proximal flange ([Fig. 1], [Fig. 2]). The patient was discharged on the fifth day with antibiotic therapy after improvement of clinical and lab tests.

Fig. 1 Endosonographic image showing deployment of the distal flange of the lumen-apposing metal stent (LAMS) within the gallbladder lumen.

Fig. 2 Both endoscopic and endosonographic view of the LAMS proximal flange released in the gastric body.

A per-oral cholecystoscopy was carried out 6 weeks later by inserting a standard gastroscope through the LAMS ([Video 1]). The gallstone was detected obstructing the gallbladder neck. Mechanical lithotripsy using a basket was performed for stone fragmentation and retrieval ([Fig. 3]). Once the gallbladder and the cystic duct insertion were clear from any residuals, the LAMS was removed with a rat-tooth forceps ([Fig. 4], [Fig. 5]). No complications related to the procedure were encountered. The patient resumed oral intake 1 day later and was discharged with no symptoms.

Video 1 Endoscopic ultrasound-guided cholecystogastrostomy and subsequent transgastric gallbladder stone toilette.

Fig. 3 Mechanical lithotripsy performed using a Dormia basket through the LAMS.

Fig. 4 Gallbladder fundus and cystic duct insertion cleared after complete extraction of stones.

Fig. 5 Cholecystogastric fistula after LAMS removal at the end of the procedure.

Advanced gallbladder endoscopic intervention is a promising option for relieving acute cholecystitis and removing gallstones in selected patients not suited for cholecystectomy or when a bridge to surgery is needed, with good technical and clinical success rates [1] [2].

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing interests

B. Mangiavillano is consultant for Taewoong.

• References

• 1 Mangiavillano B, Auriemma F, Lamonaca L. et al. A novel lumen-apposing metal stent with an electrocautery tip for different indications: initial experience in a referral center. Dig Dis 2022; 40: 526-529
• 2 Mangiavillano B, Moon JH, Crinò SF. et al. Safety and efficacy of a novel electrocautery-enhanced lumen-apposing metal stent in interventional EUS procedures (with video). Gastrointest Endosc 2022; 95: 115-122

Publication History

Article published online:
02 December 2022