Our First Two Cases of Endoscopic Ultrasound (EUS)-Guided Placement of Lumen-Apposing Metal Stent to Manage Acute Cholecystitis: Lessons Learned

Abstract

For decades percutaneous gallbladder drainage (PGD) with systemic antibiotic therapy has been the mainstay, non-surgical treatment option for acute cholecystitis in high-risk operative candidates who failed conservative management. However, PGD has several complications that occur in up to 40% of patients. More recently EUS-guided gallbladder stenting (EUS-GBS) techniques have evolved whereby a stent is placed across the duodenal or gastric wall into the gallbladder thus avoiding a percutaneous drain. Early innovative strategies using biliary stents (either plastic or self-expanding metal) proved to be equally effective to PGD but were prone to the same complications as PGD and were technically difficult to perform thus EUS-GBS never gained widespread popularity. However, there is now an FDA-approved, fully-covered, self-expanding lumen-apposing metal stent (LAMS) with a cutting tip incorporated into the catheter for EUS-guided drainage of pancreatic pseudocysts. Research from high-volume referral centers indicates that LAMS may be equally suitable for transmural gallbladder drainage and appears to be simple to place. Thus far, at our institution we have attempted two cases of EUS-GBS using a LAMS in individuals with cholecystitis who were deemed to be poor-surgical candidates. In case #1 the patient's gallbladder was distended with innumerable shadowing gallstones (thus EUS views were limited) and attempt at EUS-GBS ultimately failed because the stent was erroneously deployed between the gallbladder and duodenal wall within a space created by the catheter. The patient underwent urgent cholecystectomy with omental patch closure of the iatrogenic duodenal perforation and did well. In case #2 a critically-ill patient who had undergone PGD but had recurrent episodes of sepsis related to drain dislodgement. On EUS this patient had a well-defined gallbladder that was distended and largely homogenous thus placement of the LAMS into the gallbladder across the duodenal wall was straightforward and technically successful. This patient was soon discharged home. Our first two cases of EUS-GBS with LAMS with a cutting tip incorporated into the catheter have taught us that this technique can be effective for emergent management of cholecystitis in poor-surgical candidates. However, gallbladders with heavy stone burden and/or a thick fibrotic wall may be more technically challenging.2165_A Figure 1 No Caption available.2165_B Figure 2 No Caption available.2165_C Figure 3 No Caption available.