Su1320 SAFETY OF EUS GUIDED GALL BLADDER DRAINAGE IN GRADE 4 CHOLECYSTITIS

Abstract

Acute cholecystitis with a perforated gall bladder (GB) is described as grade 4 cholecystitis. Studies have shown higher intraoperative bile duct injuries and complications in patients with perforated GB with increased costs, increased length of stay, and increased conversion to open cholecystectomy. For, patients who are poor operative candidates, decompression can be achieved with percutaneous GB drainage. Alternatively, EUS guided GB drainage (EUS-GBD) has been shown to be safe and effective in acute cholecystitis, however, there is no existing data on EUS-GBD in patients with perforated GB. We describe a multicenter case series of EUS-GBD in the setting of grade 4 cholecystitis. We performed a multicenter retrospective review of patients with acute cholecystitis and GB perforation who underwent EUS-GBD using Lumen Apposing Metal Stents (LAMS). Technical success (TS) was defined as successful placement of EUS guided LAMS with a transduodenal or transgastric approach. Clinical success was defined as resolution of acute cholecystitis, fever, pain, and leukocytosis. A total of 5 patient underwent EUS-GBD in this multicenter cohort. Four males and 1 female with a median age of 69 (age range 58-88 years). Indications for procedure was acute cholecystitis with perforated gall bladder. Etiologies included calculus cholecystitis (N=3) and malignant biliary stricture (N=2) resulting in cystic duct obstruction. All patients were deemed non-surgical candidates due to medical comorbidities (N=5). Imaging was consistent with perforated GB (Image 1). All procedures were performed under GA with noted ASA classes 3 (N=3) and class 4 (N=2). GB perforation was observed on EUS and confirmed on cholecystoscopy (Image 2). TS and CS was observed in 100% of the cases with no procedure related complications. Antibiotics were used for an average of 8 days. Average length of procedure was 70 minutes. One patient developed stent occlusion at 1 month and again 1 year. This was treated endoscopically with removal of food debris. Average follow up was otherwise unremarkable for all patients for average of 13 months. Our case series shows it is technically feasible and safe to achieve adequate drainage using a LAMS for patients with grade 4 cholecystitis which can avoid surgery or indefinite percutaneous cholecystostomy tube placement and complications related to that. Additionally, there were no procedure related complications and all patients had resolution of inflammatory and infectious symptoms with the transmural approach. Larger prospective studies may further define the efficacy of endoscopic management in grade 4 cholecystitis using LAMS EUS-GBD approach.Image 2.GB perforation on EUS and cholecystoscopyView Large Image Figure ViewerDownload Hi-res image Download (PPT)