Benjamin Tharian, MD, MRCP (UK), FRACP, from the Center for Interventional Endoscopy, Florida Hospital, in Orlando, Florida, USA shares this VideoGIE, “Drainage of obstructed gallbladder with use of lumen-apposing metal stent.”

We demonstrate the technique of EUS-guided fine needle aspiration of a gallbladder mass and drainage of a symptomatic obstructed gallbladder (from invasive cancer), as a minimally invasive palliative treatment modality, using a LAMS (cold AXIOS, Xlumena Inc., California, USA), done in a single sitting.

An 81-year-old female patient with abdominal pain was referred for evaluation by endoscopic ultrasound (EUS). A computed tomography scan of the abdomen revealed a distended gallbladder with stones and a dilated common bile duct. Liver tests were normal.

At EUS, the bile duct appeared normal and a mass was seen obstructing the gallbladder neck causing distension. EUS-guided fine needle aspiration of the gallbladder mass revealed adenocarcinoma (Fig). As the patient experienced significant abdominal pain, a EUS-guided drainage of the gallbladder was undertaken as a palliative treatment measure.

The gallbladder was punctured via the duodenal bulb under EUS guidance, using a 19-gauge needle and a 0.025-inch guide-wire was coiled within it. After dilating the transmural tract with a tapered-tip cannula and a 4mm dilating balloon, a LAMS was deployed with the distal flange within the gallbladder lumen and the proximal flange within the duodenal bulb (video).

No procedure-related adverse events were encountered. The patient had almost instantaneous pain relief and hence was discharged home the same day at her request.

We highlight the ease and safety of EUS guided gallbladder drainage using lumen-apposing metal stents (LAMS) in patients with advanced cancer and inoperable candidates, and the increasing role of therapeutic EUS in Oncology. More invasive options done by interventional radiology or surgeons should be reserved for cases which fail the former and should be used as a second line approach.

We believe that this would encourage endoscopic management of a selected group of patients with gallbladder cancer, with diagnosis, staging and palliative drainage all done in one step. The video again high lights the fact that gallbladder diseases are now being increasingly managed by gastroenterologists.

The above procedure has been further simplified now, with the availability of the Hot AXIOS, that eliminates few of the steps and minimizes complications, in addition to making it a quicker process. This approach would be certainly preferred by patients and can be done by any advanced endoscopist who has the skill set to perform an EUS guided therapeutic procedure like cyst gastrostomy.

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