Symptomatic cholelithiasis and acute cholecystitis treated by EUS-guided gallbladder drainage with gallbladder toilette

An 81-year-old woman with a history of colorectal cancer, connective tissue disease, previous dorsal spine stabilization, and late mild cognitive impairment was admitted to our emergency department with abdominal pain, fever, and jaundice. She had experienced recurrent upper right abdominal pain for the past 2 years and had been diagnosed with cholelithiasis. Laboratory findings showed leukocytosis, elevated C-reactive protein levels, elevated alkaline phosphatase, and hyperbilirubinemia. A computed tomography (CT) scan revealed gallbladder distention and wall thickening with pericholecystic fluid and a 25-mm gallstone impacted in the infundibulum. Because of her age and comorbidities, the patient was at high risk for surgery. After joint discussion, we decided on an endoscopic ultrasound (EUS)-guided gallbladder drainage with placement of an electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) (10×20-mm Hot-Spaxus; Taewoong Medical Co., Gimpo, Korea) [1, 2]. The cholecystogastrostomy was successfully performed using the freehand technique and intrachannel release of the proximal flange (▶Fig. 1, ▶Fig. 2). The patient was discharged on the fifth day with antibiotic therapy after improvement of clinical and lab tests. A per-oral cholecystoscopy was carried out 6 weeks later by inserting a standard gastroscope through the LAMS (▶Video 1). The gallstone was detected obstructing the gallbladder neck. Mechanical lithotripsy using a basket was performed for stone fragmentation and retrieval (▶Fig. 3). Once the gallbladder and the cystic duct insertion were clear from any residuals, the LAMS was removed with a rat-tooth forceps (▶Fig. 4, ▶Fig. 5). No complications related to the procedure were encountered. The patient resumed oral intake 1 day later and was discharged with no symptoms. Advanced gallbladder endoscopic intervention is a promising option for relieving acute cholecystitis and removing gallstones in selected patients not suited for cholecystectomy or when a bridge to surgery is needed, with good technical and clinical success rates [1, 2].