An 89-year-old woman presented to our department having experienced acute cholecystitis
a few weeks previously. Her comorbidities, chronic kidney disease, and congestive
heart failure meant she was not a suitable candidate for surgery. She underwent EUS-guided
gallbladder drainage, which was performed without complications. During this procedure,
a 10-mm × 10-mm lumen-apposing metal stent (LAMS) (Hot Axios; Boston Scientific) was
implanted for gallbladder drainage. A few days later, the patient complained of right-upper
quadrant abdominal pain and fever, and a new acute cholecystitis episode was diagnosed.
Upper endoscopy with a therapeutic endoscope (GIF-1TH190; Olympus) was performed.
The endoscope was introduced as far as the duodenum, where it became evident that
the LAMS was obstructed by a biliary stone impacted in the stent lumen ([Fig. 1]; [Video 1]). Electrohydraulic lithotripsy (EHL) (1.9-Fr, 375-cm Biliary EHL Probe Autolith;
Boston Scientific) was performed to fragment the obstructive biliary stone. The EHL
probe was introduced through the endoscope, and fragmentation with the infusion of
saline was started ([Fig. 2]). The gallbladder stone was broken into multiple fragments that were removed with
a Dormia basket. During the procedure, which lasted about 60 min, purulent secretion
was seen draining from the gallbladder. The gallbladder wall showed a 10 mm-fistula
with some fragmented stones within the cavity ([Fig. 3]); these were removed with a Roth Net retriever. To prevent renewed LAMS occlusion,
placement of a plastic double-pigtail stent was decided on ([Fig. 4]). No complications were observed in the patient; she tolerated the procedure and
was discharged home a few days later.
Fig. 1 Lumen-apposing metal stent (LAMS) obstructed by a biliary stone impacted in the stent
lumen.
Video 1 Biliary stone occluding a lumen-apposing metal stent treated with electrohydraulic
lithotripsy in a patient who had previously undergone endoscopic ultrasound-guided
cholecystoduodenostomy.
Fig. 2 Fragmentation of biliary stone by means of electrohydraulic lithotripsy.
Fig. 3 A 10-mm fistula in the gallbladder wall with fragmented stones in the cavity.
Fig. 4 Placement of a plastic double-pigtail stent to prevent renewed occlusion.
EUS-guided gallbladder drainage in patients who are not candidates for surgery is
a safe technique and has a low complication rate. In patients with large stones, recurrent
cholecystitis, impaction, and LAMS obstruction can occur [1]
[2]. EHL and laser lithotripsy are two useful techniques that allow fragmentation of
stones; EHL generates high-amplitude hydraulic pressure waves, while laser lithotripsy
uses a laser beam with repetitive pulses of laser energy to create a mechanical shockwave
[3]
[4]. EHL is a safe option to resolve LAMS occlusion in cholecystoduodenostomy.
Endoscopy_UCTN_Code_CPL_1AL_2AD
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