Endoscopic Ultrasound-Guided Gallbladder Drainage After Roux-En-Y Gastric Bypass: It Can Hide, but It Can‘t Run!

Abstract

In patients with acute cholecystitis who are non-operative candidates, percutaneous cholecystostomy (PC) catheter placement is used for gallbladder decompression Removal of the catheter can lead to recurrence of cholecystitis. Leaving drain in place can cause infection, pain and dislodgment. Routine catheter maintenance and exchanges adversely affect quality of life. EUS-guided approach may be used to convert PC drainage to internal biliary drainage. 33-year-old woman with a history of Roux-en-Y gastric bypass presented with septic shock. She was actively abusing alcohol (MCV 105), malnourished (Albumin 2.0), coagulopathic (INR 2.0), thrombocytopenic (Platelets 58 k), and requiring frequent large volume paracentesis Abdominal CT scan showed acute acalculous cholecystitis. Patient started on broad spectrum antibiotics, vasopressors, deemed to be a prohibitive operative candidate and underwent placement of an 8 French decompression PC catheter (Fig 1) by Interventional Radiology. Due to severe discomfort from the PC catheter, taken for conversion to internal biliary drainage via endoscopic ultrasound. Stricture found at the G-J anastomosis. Contrast injected across the stricture, confirming a patent jejunal limb. Stricture was dilated to 18 mm. EUS scope maneuvered into the jejunal limb, gallbladder visualized endosonographically. Hyperechoic material consistent with sludge seen within an enlarged gallbladder. Site within the jejunum chosen, where gallbladder wall was within 1 cm (Fig 2). Gallbladder punctured with a 19 gauge FNA needle under EUS guidance. 10 mm by 10 mm cautery-enhanced LAMS placed creating a cholecystojejunostomy. 7 Fr by 4 cm plastic double pigtail stent placed through LAMS to maintain patency of the metal stent and prevent the backwall of gallbladder from impacting the metal stent causing bleeding or dislodgement (Fig 3). The patient did well following EUS-guided cholecystojejunostomy. 3 weeks later, a cholecystogram was performed. Contrast flowed from a decompressed gallbladder and into the jejunum across a patent cholecystojejunostomy via the LAMS. The PC catheter was then removed. The patient did well and was discharged home. EUS guided-conversion of percutaneous gallbladder drainage to internal drainage via a cholecystojejunostomy using a LAMS in a non-surgical patient with Roux-en-y gastric bypass is feasible, although the procedure is technically challenging and requires more expertise compared to primary EUS-guided gallbladder drainage.1702_A Figure 1 No Caption available.1702_B Figure 2 No Caption available.1702_C Figure 3 No Caption available.Watch the video: https://goo.gl/rfav8w