S2885 Endoscopic Ultrasound-Guided Drainage of a Remnant Gallbladder

Abstract

Introduction: Endoscopic Ultrasound (EUS) guided drainage of a remnant gallbladder (RGB) with lumen-apposing metal stents (LAMS) can be safely performed for suppurative cholecystitis and choledocholithiasis following subtotal cholecystectomy (STC). Case Description/Methods: A 68-year-old man presented with recurrent bacteremia secondary to symptomatic RGB after undergoing STC for severe necrotizing gallstone pancreatitis. His preceding course was complicated by infected walled-off pancreatic necrosis, recurrent choledocholithiasis with ascending cholangitis, liver abscess, and bacteremia. His treatments included EUS-guided necrosectomy, multiple endoscopic retrograde cholangiopancreatopgraphies (ERCPs) with unsuccessful attempts at transpapillary gallbladder drainage, and percutaneous cholecystostomy followed by laparoscopic STC. Given his life-threatening complications and poor surgical candidacy EUS-guided drainage of the RGB was pursued. Linear EUS identified the RGB measuring 19.4mm in diameter. Using a 19-gauge FNA needle, the RGB was instilled with 80cc of sterile saline to a diameter of 28.5mm (Figure a). EUS-guided cholecystogastrostomy was then performed using a 10 x 15 mm electrocautery-enabled access catheter-enhanced LAMS. The LAMS was dilated to 12mm sequentially using a controlled radial expansion balloon. Multiple large, pigmented stones passed with several remaining in the gallbladder (Figure b). A 10Fr by 5cm double pigtail stent was passed over a wire into the gallbladder to complete the procedure (Figure c). At one month follow-up ERCP, the LAMS was removed leaving a mature gastrocholecystic fistula. No recurrence of symptoms noted at 12-month follow-up. Discussion: Laparoscopic cholecystectomy after recovery of gallstone pancreatitis is recommended to reduce risk of recurrent pancreatitis. In some patients, difficult anatomy and inflammation necessitates STC to avoid injury to the extrahepatic bile ducts and surrounding blood vessels. STC is associated with significant morbidity. Completion cholecystectomy for symptomatic complications from RBG is recommended if possible. However, our patient was deemed a poor surgical candidate. Transpapillary drainage of the RBG was also precluded by difficult anatomy with sharp angulation at the confluence of the common hepatic and cystic ducts. This case describes the novel application of EUS-guided drainage of an RBG as a safe and effective alternative to completion cholecystectomy for patients who are poor operative candidates.Figure 1.: EUS used to measure dimensions of remnant gallbladder after injecting 80mL of sterile saline (A). Cholecystogastrostomy was performed using a 10 mm X 15 mm LAMS with cautery tip over a wire and dilated using a controlled radial expansion balloon (B). A double pigtail stent was placed through the lumen of the LAMS (C).