Aims:
Acute cholecystitis (AC) is a serious condition, especially in elderly patients, requiring
urgent treatment. Surgery is the standard option, while EUS-guided gallbladder drainage
is an emerging alternative strategy as definitive treatment, in poor surgical candidates.
To overcome some limitations of past techniques, a novel endoscopic device containing
a lumen-apposing metal stent with an electrocautery (ECE-LAMS) has been developed
(Hot Axios System, Boston Scientific, USA).
Methods:
We report a single-centre experience of 5 high risk patients (mean age: 90 years,
range 81 – 98), male/female: 2/3, with AC treated with ECE-LAMS.
Results:
Stent placement was technically successful in 4 of 5 patients (80%). Endoscopic approach
was transgastric in 1 patient and through the duodenum in 3 cases. 10 × 10-mm stent
was placed in 2 patients, 15 × 10-mm stent in the others. Access to gallbladder was
obtained directly with the device; release of the first flange of the stent was performed
under EUS-guide, while the second under endoscopic view, overall without fluoroscopic
assistance. Total mean procedural time was 18 min (range 8 – 41), whereas the mean
stent deployment time was 3 min (range 2 – 5). In the failure case, inability to release
the distal flange of the stent inside the gallbladder occurred, resulting in perforation.
The proximal flange was released in the stomach and then removed with a snare; the
gastric leakage was repaired using over-the-scope clip and patient underwent to cholecystectomy.
The technical failure seemed to be caused by hard approach to gallbladder, either
by stomach and duodenum, and by its wall thickness, as shown in the surgical specimen.
Resolution of AC was observed in all patients with technically successful stent placement.
3 of them were discharge home within 1 week (mean length of hospitalization after
the procedure: 3 days, range 2 – 5 days),1 was transferred from intensive care unit
to long-term care unit 8 days after the exam. The mean follow-up was 204 days (range
90 – 485), without complications.
Conclusions:
This novel device for poor surgical patients with AC is safe, effective, with high
technical and clinical success rate. However, it remains a challenging procedure also
in expert hands. Further studies are needed to confirm these promising initial experience.
