EUS-GUIDED GALLBLADDER DRAINAGE (EUS-GBD) WITH LUMEN-APPOSING METAL-STENT – BEYOND BILIARY ISSUES. SEDATION AND AIRWAYS MANAGEMENT, ICU ADMISSION AND GENERAL OUTCOMES

Aims:

EUS-guided gallbladder drainage (EUS-GBD) in high-risk surgical patients with acute cholecystitis is a safe procedure, with a high success rate. Several studies have been published dealing with technical, clinical outcomes, procedural adverse events; moreover, comparison with surgery, percutaneous drainage, trans-papillary endoscopic drainage have been performed.

To our knowledge, no data on procedural issues have been clearly stated, in terms of type of sedation administered, airways management, need for ICU admission, length of stay and long-term survival.

Methods:

We enrolled patients with clinical, biochemical and radiological diagnosis of severe acute cholecystitis, who underwent EUS after being considered contraindicated for surgery at multidisciplinary evaluation. All procedures have been conducted with the supervision of an anesthesiologist.

Results:

20 patients were consdered but in 6 case EUS-GBD was not indicated because of no signs of cholecystitis (no.3), obstructive cholangitis (no.2), no signs of biliary stones or inflammation (no.1). In 14 patients (8 male; 78-year-old [69 – 91]) EUS-GBD was considered indicated; in 1 case, no EUS operative window was identified and the drainage was not performed. Trans-duodenale drainage was performed in 10 out of 13 cases (76.9%). Clinical success was achieved in 11/13 cases (84.6%). 2 patients (14.3%) required ICU admission, before the procedure, because of biliary septic shock. 2 (14.3%) patients required general anesthesia with airways intubation, 9 (64.3%) required deep sedation with propofol while, in 3 cases (21.4%) were managed with fentanyl and midazolam. ICU length of stay was 8 [2 – 14] days; length of stay was 9 [7 – 32] days; in-hospital mortality was 7.1%; 1-month survival was 92.9%; 6-month survival was (6/7) 85.7%. Elective cholecystectomy was performed in 1 patient because of recurrent cholecystitis due stent occlusion.

Conclusions:

EUS-GBD was a safe and effective technique; the procedure could be performed without general anesthesia and airways intubation in most cases (> 85%) leading to very low anesthesiological complications and mortality.