Endoscopic ultrasound-guided gallbladder drainage after distension with a high density solution (hyaluronic acid)

A 95-year-old woman presented to the emergency department with clinical deterioration and vomiting. An abdominal computed tomography scan showed acute cholecystitis. She was not a candidate for surgery, therefore a percutaneous cholecystostomy was performed. In order to internalize drainage, 3 days later, the decision was made to convert the percutaneous cholecystostomy to internal transmural gallbladder drainage using a lumen-apposing metal stent (LAMS) ([Video 1]). The gallbladder was initially difficult to visualize owing to the presence of a 3 × 2-cm perivesicular abscess ([Fig. 1]).

Video 1 Endoscopic ultrasound-guided gallbladder drainage with a lumen-apposing metal stent after the infusion of hyaluronic acid through a percutaneous catheter.

Fig. 1 Endoscopic ultrasound image showing a 3 × 2-cm perivesicular abscess.

After the abscess had been completely emptied with a 19-gauge needle, a contracted gallbladder was identified. Saline and contrast were used to distend the gallbladder through the percutaneous catheter; however, the contrast quickly left the gallbladder through the cystic duct and the small perforation it contained. It was therefore not possible to distend the gallbladder enough to place a LAMS safely ([Fig. 2 a]). A 2 % hyaluronic acid solution was then infused through the percutaneous catheter ([Fig. 2 b]), allowing the gallbladder to distend sufficiently to place a 10 × 10-mm electrocautery-enhanced LAMS (Hot Axios; Boston Scientific, Marlborough, Massachusetts, USA). Finally, a 7-Fr double-pigtail stent was placed through the LAMS. The next day, the percutaneous catheter was removed. The patient improved clinically and was discharged several days later.

Fig. 2 Fluoroscopic images showing: a the gallbladder distended with saline and contrast instilled through the percutaneous catheter, and the passage of contrast into the duodenum via the patent cystic duct; b the gallbladder distended with hyaluronic acid through the percutaneous catheter.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective and safe technique for the treatment of acute cholecystitis in high risk patients [1]. In patients with previous percutaneous cholecystostomy, it is possible to convert the percutaneous drainage to internal transmural drainage using EUS guidance [2]. The percutaneous catheter allows the infusion of contrast to distend the gallbladder and achieve a suitable target. If, however, the cystic duct is patent, the contrast may quickly empty from the gallbladder, preventing adequate distension. In this scenario, the infusion of a viscous solution, in this case hyaluronic acid, can enable distension of the gallbladder by slowing the emptying through the cystic duct. EUS-guided injection of viscous solutions for gallbladder distension may be a helpful technique for EUS-guided gallbladder drainage in such challenging cases.

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Competing interests

Drs. Aparicio and Berzin are consultants for Boston Scientific. The remaining authors declare that they have no conflict of interest.

• References

• 1 Teoh AYB, Perez-Miranda M, Kunda R. et al. Outcomes of an international multicenter registry on EUS-guided gallbladder drainage in patients at high risk for cholecystectomy. Endosc Int Open 2019; 7: E964-E973
• 2 Minaga K, Yamashita Y, Ogura T. et al. Clinical efficacy and safety of endoscopic ultrasound-guided gallbladder drainage replacement of percutaneous drainage: A multicenter retrospective study. Dig Endosc 2019; 31: 180-187

Publication History

Article published online:
17 April 2020