Mo1310 CHOLECYSTOENTEROSTOMY AS AN ALTERNATIVE TO CONVENTIONAL TREATMENT FOR CHOELCYSTITIS AND THE ROLE OF SEROTROPIC STENTS

Abstract

Laparoscopic cholecystectomy for cholecystitis is the standard of care . Percutaneous cholecystostomy is used in patients deemed unfit for surgery . Endoscopic interventions include natural orifice trans-luminal endoscopic surgery (NOTES), per-oral endoscopic trans-papillary drainage and endoscopic ultrasound- guided endoluminal gallbladder drainage. There are a few EUS- specific stents that have shown promise through decreased tissue ingrowth, leakage and migration yet ensure drainage through apposition of lumens. Our index case highlights one stent but autopsy findings did not demonstrate apposition. A 26-year-old female presented with decompensated alcoholic cirrhosis with ascites, abdominal pain and hyperbilirubinemia. After a negative serologic evaluation, we requested a magnetic resonance cholangiopancreatography (MRCP) which demonstrated multiple gallstones and a mildly thickened gallbladder wall. We performed an endoscopic ultrasound which confirmed cholelithiasis, gallbladder distention and estimated the gall bladder wall thickness to be 2.4 mm. We then performed a cholecystoduodenostomy using the AXIOS™ stent and electrocautery enhanced delivery system (AXIOS, Boston Scientific, Natick, MA). Within 24 hours, the patient showed significant improvement in her abdominal pain. Second-look esophagogastroduodenoscopy 48 hours after the initial procedure to evaluate post procedural anemia was unrevealing. Two weeks after gallbladder drainage her hepatic status worsened and she expired. We participated in a limited autopsy to evaluate the effect of the stent invivo and reviewed the histological properties of the lumen. There was evidence of focal adherence of the gallbladder to the duodenum at the site of stent deployment with circumferential serosal formation. Figure 1. The diameter of the tract was 15 mm which was the diameter of the stent used. Histology demonstrated gallbladder serosa continuous with the neo-serosa of the tract and there was no evidence of significant adhesions. Figure 2. The AXIOS™ stent is FDA approved for trans-enteric drainage of pancreatic pseudocysts but recently has been used successfully for gallbladder drainage. Data describing adherence of the gallbladder to the duodenal wall in human subjects using the AXIOS™ stent is limited. Animal model studies have shown serosal adhesion of the stomach to gallbladder at 4 weeks. We observed serosal formation rather than adhesion after two weeks. Studies indicate that adhesions occur after disruption of serosal surfaces and tissue apposition. If tissue apposition does not occur, a new serosal surface will be formed similar to cutaneous wound healing. Trans-luminal stents likely decompress and drain but also are a conduit for serosal formation without direct tissue apposition. We refer to this process as “serotropism.”Figure 2. Histology showing continuation of gallbladder serosa with neo-serosa of the drainage tract created by the stent.View Large Image Figure ViewerDownload Hi-res image Download (PPT)