EUS-guided gallbladder drainage with LAMS in acute cholecystitis in high-risk surgical patients: single-center prospective study with long-term follow-up

Aims EUS-guided gallbladder drainage (EUS-GBD) with Lumen Apposing Metal Stent (LAMS) is mini-invasive approach for gallbladder drainage, in unfit for surgery (UFS) patients with acute cholecystitis.

Methods From July 2019 to April 2024, we prospectively enrolled all the 33 consecutive high-risk UFS patients with acute cholecystitis (mild and severe grade according to the ASGE lexicon) treated with EUS-GBD using an Elettrocautery-enhaced LAMS in a free-hand fashion. The primary outcomes were technical (correct apposition of the two flanges) and clinical (normalization of systemic inflammatory tests and radiological pattern after 7 days) success. Secondary aims were to assess the survival rate, cholecystitis recurrence and conversion to cholecystectomy.

Results 33 patients (17 men and 16 women, with an average age of 82.63±9,52 years.) were enrolled. Electrocautery-enhanced LAMS was systematically used (Hot-Axios Stent): 18 with trans-gastric and 15 with trans-duodenal access, choosing between 4 different dimensions [10x10 (8), 10x15 (11), 15x15 (11), 10x20 (3)]. The preference in access route was dictated by the patient's clinical condition, favouring trans-duodenal access in patients definitively considered as UFS, and trans-gastric route for the temporarily UFS patients who could potentially undergo cholecystectomy in the future, given improvement of their general condition. Technical success was 93,9% (31/33). The failure cases were due to a first-flange maldeployment and were managed by a novel intra-operative LAMS placement (1) and by a percutaneous approach (1). Mechanical lithotripsy using Dormia basket was performed just in one case. Adverse events (AEs) were mild (2/33): one self-limiting bleeding and one stent occlusion, treated both with LAMS removal. Final clinical success was 100%. LAMS was left in place in 27/33 (81,8%) patients with major time of stent left in place of 761 days and removed in 6 cases (time removal after 27.16±14.9 days). Medium time of prospective follow-up was 298±322 days [1344 was the longest time]. 2 patients died within the first month after the LAMS placement for poor clinical conditions, 21 patients died during the follow-up for uncorrelated etiology and 10 patients are still alive. 3 patients (9%) had cholecystitis recurrence managed with antibiotic therapy. Laparoscopic cholecystectomy was never performed considering the permanent condition of UFS

Conclusions EUS-GBD with LAMS is an effective treatment option for fragile patients, with high technical and clinical success rates, minimum rate of AEs and increased time of survival rate. The recurrence of cholecystitis has a low rate and it can be easily managed by conservative way in almost the all cases, making surgery unnecessary.

 

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Conflicts of Interest

Di Mitri Roberto is a consultant for Boston Scientific

Publication History

Article published online:
27 March 2025