Endoscopic ultrasound-guided gallbladder drainage using a novel cautery-enhanced, endoscopist-deployed lumen-apposing metal stent

An 85-year-old woman presented with right upper abdominal pain and fever. Examination revealed tenderness in the right hypochondrium with a positive Murphy’s sign. White cell count was 16.3 × 109/L, but liver function was normal. Transabdominal ultrasound confirmed acute cholecystitis with a 6-mm cystic duct stone. Owing to the patient’s pre-existing Alzheimer’s disease and frail pre-morbid condition, we decided for endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) after discussion with the patient’s main caregiver [1] [2] [3].

The procedure was performed in an endoscopy suite with fluoroscopy capabilities and the patient was placed in the prone position under conscious sedation ([Video 1]). A linear echoendoscope (GF-UCT260; Olympus, Tokyo, Japan) was advanced to the first part of the duodenum and a distended gallbladder up to 10 cm and a 6-mm cystic duct stone were identified ([Fig. 1]). There were no stones in the common bile duct.

Video 1 Use of a novel cautery-enhanced, endoscopist-deployed lumen-apposing metal stent to perform endoscopic ultrasound-guided gallbladder drainage.

Fig. 1 Endoscopic ultrasound images of a distended gallbladder and cystic duct stone. Arrow (←) shows the cystic duct stone.

EUS-GBD was performed via direct puncture with a novel cautery-enhanced, lumen-apposing metal stent (LAMS) (Hanarostent Z-EUS IT; M.I. Tech, Gyeonggi-do, South Korea) ([Fig. 2]). This is a 12 mm (diameter) × 30 mm (length) fully-covered, lumen-apposing stent with an inter-flange distance of 22 mm. The opening and deployment of the proximal and distal flanges of the stent were fully controlled by the endoscopist. The opening of the distal flange was confirmed on endoscopic ultrasound (EUS) ([Fig. 3]), while the proximal flange was visualized endoluminally ([Fig. 4]). The procedure took 20 minutes and there was good drainage of purulent bile at the end. Abdominal X-ray confirmed a good stent opening and the presence of the air cholecystogram ([Fig. 5]). The patient’s fever subsided and her white cell count normalized by day two after the procedure and she was discharged with a one-week course of oral antibiotics.

Fig. 2 The cautery-enhanced, lumen-apposing metal stent.

Fig. 3 Endoscopic ultrasound image of the distal flange of stent fully deployed. Arrow (→) shows the distal flange of the stent.

Fig. 4 Endoluminal image of the proximal flange of the fully deployed stent.

Fig. 5 Abdominal X-ray of the stent and air cholecystogram. Arrow (←) shows the lumen-apposing metal stent; * shows the air cholecystogram.

The availability of a cautery-enhanced, endoscopist-deployed LAMS allows precise stent placement under EUS guidance to drain the gallbladder into the duodenum. It makes for safer stent deployment in tight spaces and reduces the need for an experienced assistant.

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• References

• 1 James TW, Baron TH. EUS-guided gallbladder drainage: a review of current practices and procedures. Endosc Ultrasound 2019; 8: S28-S34
• 2 Teoh AYB, Kitano M, Itoi T. et al. Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: an international randomised multicentre controlled superiority trial (DRAC 1). Gut 2020; 69: 1085-1091
• 3 Cho SH, Oh D, Song TJ. et al. Comparison of the effectiveness and safety of lumen-apposing metal stents and anti-migrating tubular self-expandable metal stents for EUS-guided gallbladder drainage in high risk surgical patients with acute cholecystitis. Gastrointest Endosc 2020; 91: 543-550