Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is considered an effective
therapy for acute cholecystitis in patients who are unfit for surgery [1]
[2]
[3].
We describe the case of a 90-year-old woman admitted for septic shock due to acute
cholecystitis, who underwent EUS-GBD after being considered unfit for surgery because
of advanced age and comorbidities (obesity, coronary heart disease) ([Video 1]). Transgastric EUS-GBD with a lumen-apposing metal stent (Hot-Axios, 10 × 10 mm,
Boston Scientific, Marlborough, Massachusetts, USA) was performed using a forward-view
echoendoscope (TGF-UC180J; Olympus, Tokyo, Japan) after failure in identifying a safe
window with a curvilinear-array echoendoscope [4]. Subsequently, the patient recovered and returned home after 1 week.
Video 1 Endoscopic ultrasound-guided gallbladder drainage with a lumen-apposing metal stent;
endoscopic view of the proximal flange deployment. Computed tomography showing recurrent
cholecystitis, stent still in place, and gastric tissue overgrowth; endoscopic view
of nearly complete stent occlusion due to tissue overgrowth, and gallbladder lumen
with pus and debris. Endoscopic and fluoroscopic view of a biliary metal stent placed
through the obstructed Axios stent (Boston Scientific, Marlborough, Massachusetts,
USA). Elective open cholecystectomy, showing the two metal stents between the gastric
antrum and gallbladder.
However, she was readmitted after 2 weeks because of recurrence of cholangitis and
severe sepsis. Computed tomography showed cholecystitis despite the stent still being
in place. Almost complete stent occlusion due to tissue overgrowth was observed endoscopically.
The gallbladder lumen contained a large amount of pus, which was drained using a nasobiliary
tube, leading to a temporary clinical improvement. At multidisciplinary discussion,
surgery was still contraindicated due to sepsis and hemodynamic instability, and therefore
an endoscopic rescue strategy was planned. We placed a fully covered biliary metal
stent over a guidewire through the obstructed Axios, achieving good biliary drainage
[5].
Two months later, due to the persistence of biliary pain and ultrasound signs of mild
cholecystitis, without systemic sepsis, the patient was considered suitable for elective
cholecystectomy. Surgery was not impeded by the presence of the stents. In particular,
disconnecting the gallbladder and suturing the gastric wall were undemanding.
We speculate that the suboptimal clinical outcome of EUS-GBD in our patient might
have been due to the greater distance between the gallbladder and the antrum, as opposed
to the duodenum, leading to traction on the stent and subsequent tissue overgrowth.
We showed that surgery could be an effective rescue strategy, even after failure of
EUS-GBD.
Endoscopy_UCTN_Code_CPL_1AL_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
