Transgastric gallstone extraction

Dr. Takao Itoi

Takao Itoi, MD, PhD, FASGE from the Tokyo Medical University in Tokyo, Japan presents this video case “Transgastric large gallstone extraction in a patient with acute cholecystitis through a lumen-apposing metal stent (with video)” from the April issue.

A Tokyo guideline in 2013 proposed that percutaneous transhepatic gallbladder drainage (PTGBD) is considered a safe alternative to early cholecystectomy, especially in surgically high-risk patients with acute cholecystitis. Endoscopic gallbladder drainage including naso-gallbladder drainage and gallbladder stenting via a transpapillary are also alternative methods in acute cholecystitis, but both of them have technical difficulties resulting in lower success rates than that of PTGBD. Recently, endoscopic ultrasonography-guided transmural gallbladder drainage (EUS-GBD) has emerged as a special technique for EUS-GBD. However, there is no dedicated stent for this procedure. In this study, we developed a novel biflanged lumen-apposing metal stent (AXIOS, Xlumena, CA, USA) for EUS-guided gallbladder drainage in a patient with acute cholecystitis due to a large gallstone. In addition to drainage, gallstone was successfully removed by using standard upper GI endoscope thought the metal stent.

Figure 1

Figure 1. A, Mechanicallithotripsy was performed on the large gallstone. B, Complete stone removal from the gallbladder.

Several investigators have reported that procedure-related adverse events due to EUS-GBD occurred in approximately 11%. Types of adverse events were mild grade, like pneumoperitoneum and bile leak with or without bile peritonitis in half of cases. There were no fatal adverse events. Double pig-tail plastic stents or pig-tail type naso-gallbladder catheter had been used for this procedure. However, they have several risks of unexpected complications, such as peritonitis due to purulent bile leak caused by stent occlusion, migration and inadvertent catheter dislodgement or self-removal. Recently, “AXIOS stent” which is a dedicated biflanged, fully-covered metal stent for EUS-GBD, has emerged. We believe that EUS-GBD using “AXIOS stent” appears to be safe and effective. In this study, we clarified the possibility of endoscopic gallstone removal after AXIOS stent placement. Although the gallstone removal procedure by interventional EUS using lumen-apposing metal stents is not yet established, it appears to be one of the options for selected patients, such as those who are not candidates for surgical interventions.

Watch the video here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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