A 72-year-old man, with a history of myelodysplastic syndrome with chemotherapy and
previous choledocholithiasis treated by endoscopic extraction, presented with acute
cholecystitis. Because of his co-morbidities, he was not a candidate for surgery.
Therefore, he underwent successful endoscopic ultrasound (EUS)-guided transduodenal
gallbladder drainage using a lumen-apposing metal stent (LAMS). The patient’s clinical
status worsened, with peritoneal signs 2 days later. Abdominal computed tomography
(CT) was done which showed the LAMS in place, and a possibly perforated gangrenous
gallbladder.
After discussion with the surgical team, the decision was made to perform an emergent
laparoscopic cholecystectomy. However, to facilitate the cholecystectomy, the cholecystoduodenal
fistula ideally needed to be closed endoscopically.
During upper endoscopy, the endoscope was advanced into the duodenal bulb, through
the previously placed LAMS, and into the gallbladder cavity ([Video 1]). After suctioning of bile and removal of numerous gallstones, a moderate-size defect
was visualized within the gallbladder wall ([Fig. 1]). Under fluoroscopic guidance, the endoscope was advanced into the peritoneum. Large-volume
peritoneal lavage was performed. Following this, the LAMS was removed endoscopically,
and the duodenal defect was successfully closed with an over-the-scope clip.
Video 1 A combined endoscopic and surgical approach for delayed perforation gangrenous gallbladder.
Fig. 1 A moderate-size defect within the gallbladder cavity in a 72-year-old man with co-morbidities
who had undergone successful endoscopic ultrasound (EUS)-guided transduodenal gallbladder
drainage using a lumen-apposing metal stent (LAMS).
Subsequently, the patient underwent an emergent laparoscopic cholecystectomy ([Video 1]). During the surgery, the gallbladder wall appeared to be gangrenous. A successful
laparoscopic cholecystectomy was performed with no evidence of the duodenal defect
during surgery; therefore, primary closure of the duodenum was not necessary. The
patient was discharged in good clinical condition 8 days after the cholecystectomy.
EUS-guided gallbladder drainage has been shown to be a safe and efficacious approach
for gallbladder drainage [1]
[2]. However, the usage of LAMS should be avoided in the gangrenous gallbladder. Transduodenal
gallbladder drainage may make laparoscopic cholecystectomy difficult in patients who
subsequently become a surgical candidate. This case demonstrates successful management
of a delayed perforated gangrenous gallbladder with a combined endoscopic and surgical
approach.
Endoscopy_UCTN_Code_CPL_1AM_2AZ
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
