Aims EUS-guided gallbladder drainage (EUS-GBD) with Lumen Apposing Metal Stent (LAMS)
is mini-invasive approach for gallbladder drainage, in unfit for surgery (UFS) patients
with acute cholecystitis.
Methods From July 2019 to April 2024, we prospectively enrolled all the 33 consecutive high-risk
UFS patients with acute cholecystitis (mild and severe grade according to the ASGE
lexicon) treated with EUS-GBD using an Elettrocautery-enhaced LAMS in a free-hand
fashion. The primary outcomes were technical (correct apposition of the two flanges)
and clinical (normalization of systemic inflammatory tests and radiological pattern
after 7 days) success. Secondary aims were to assess the survival rate, cholecystitis
recurrence and conversion to cholecystectomy.
Results 33 patients (17 men and 16 women, with an average age of 82.63±9,52 years.) were
enrolled. Electrocautery-enhanced LAMS was systematically used (Hot-Axios Stent):
18 with trans-gastric and 15 with trans-duodenal access, choosing between 4 different
dimensions [10x10 (8), 10x15 (11), 15x15 (11), 10x20 (3)]. The preference in access
route was dictated by the patient's clinical condition, favouring trans-duodenal access
in patients definitively considered as UFS, and trans-gastric route for the temporarily
UFS patients who could potentially undergo cholecystectomy in the future, given improvement
of their general condition. Technical success was 93,9% (31/33). The failure cases
were due to a first-flange maldeployment and were managed by a novel intra-operative
LAMS placement (1) and by a percutaneous approach (1). Mechanical lithotripsy using
Dormia basket was performed just in one case. Adverse events (AEs) were mild (2/33):
one self-limiting bleeding and one stent occlusion, treated both with LAMS removal.
Final clinical success was 100%. LAMS was left in place in 27/33 (81,8%) patients
with major time of stent left in place of 761 days and removed in 6 cases (time removal
after 27.16±14.9 days). Medium time of prospective follow-up was 298±322 days [1344
was the longest time]. 2 patients died within the first month after the LAMS placement
for poor clinical conditions, 21 patients died during the follow-up for uncorrelated
etiology and 10 patients are still alive. 3 patients (9%) had cholecystitis recurrence
managed with antibiotic therapy. Laparoscopic cholecystectomy was never performed
considering the permanent condition of UFS
Conclusions EUS-GBD with LAMS is an effective treatment option for fragile patients, with high
technical and clinical success rates, minimum rate of AEs and increased time of survival
rate. The recurrence of cholecystitis has a low rate and it can be easily managed
by conservative way in almost the all cases, making surgery unnecessary.
