1335 Unchewed Food: The Enemy of Lumen-Apposing Metal Stent Placement in EUS-Gallbladder Drainage

Abstract

INTRODUCTION: Lumen-apposing metal stents (LAMS) represent a novel therapeutic endoscopic tool for the treatment of acute cholecystitis in high-risk surgical patients via transluminal EUS guided gallbladder (GB) drainage with reported 92-98% success rates. We describe a patient's successful EUS guided drainage and subsequent clinical deterioration after food related LAMS occlusion. CASE DESCRIPTION/METHODS: A 63-year-old man with extensive cardiopulmonary disease, GB hydrops, chronic cholecystitis and prior course of decompression with percutaneous cholecystostomy tube (PTC), was re-evaluated for worsening post-prandial abdominal pain. A CT showed a hydropic GB with layering stones and sludge, concerning for cholecystitis. Semi-urgent decompression with IR cholecystostomy tube vs. EUS-GB drainage was suggested because of his poor surgical candidacy. The patient declined PTC due to reduced quality of life and lack of symptomatic relief in the past. A linear EUS evaluation showed a distended, thick walled GB (12 cm in size) with sludge and debris. A cholecystoenterostomy via doppler EUS was created, followed by deployment of a 15 mm LAMS stent with immediate drainage of copious purulent bile. A 7 Fr × 7 cm double pigtail stent was placed across the LAMS. Despite a technically successful procedure, the patient did not experience clinical improvement. A follow up CT demonstrated decreased GB distention, appropriate LAMS position and related intraluminal GB gas; yet increased GB wall thickening, pericholecystic fluid, and fat stranding in the perihepatic region were consistent with worsening acute cholecystitis. A repeat EGD was performed to ensure proper LAMS location and patency. Large unchewed food pieces in the duodenal bulb and an at least partially occluded LAMS, due to food-debris, were discovered. The LAMS and GB lumen were cleared of food debris using a combination of forceps and water irrigation. The patient was placed on a full liquid diet and subsequently demonstrated clinical improvement. DISCUSSION: EUS-guided GB drainage with LAMS placement is a viable alternative to cholecystectomy for high risk surgical candidates when performed in clinical centers of expertise. Procedural success is high, yet lack of clinical improvement may require further evaluation for possible LAMS occlusion. We describe a case of lack of improvement due to documented occlusion of the LAMS related to poorly chewed food. Dietary counseling for patients post LAMS placement may be beneficial.