Post written by Catherine Frakes Vozzo, DO, and Prabhleen Chahal, MD, from the Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio.
The purpose of our case series was to assess the safety of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) in patients requiring chronic anticoagulation. EUS-GBD is performed to treat acute cholecystitis in patients who are not candidates for cholecystectomy due to medical comorbidities. EUS-GBD related bleeding in patients on chronic anticoagulants is not clearly defined or reported.
In our single-center prospectively maintained database, we identified 5 patients who required long-term anticoagulation and underwent EUS-GBD via electrocautery-enhanced lumen-apposing metal stent for management of acute cholecystitis. These patients had significant medical comorbidities and were deemed non-operative candidates by the surgical consult team. Anticoagulation was withheld before (7-24 hours) and after (9-48 hours) the procedure. A majority (4/5) of patients were placed on intravenous heparin, and the mean PTT on the day of the procedure was 59.3. The decision to interrupt anticoagulation was made in conjunction with the primary medical service and gastroenterology team based on the indication and overall risk for bleeding. The study findings were notable for clinical and technical success of 100%. There were no adverse events, including immediate or delayed bleeding post resumption of anticoagulation.
Our video depicts the EUS-GBD technique at our institution. Some theorize that the bleeding risk is low due to use of electrocautery-enhanced LAMS as well as the tamponade effect that occurs between the enteric and gallbladder lumen. It is also important to know that the vascular supply of gall bladder is along the posterior wall. Although there is still insufficient data to give definitive guidelines for anticoagulation withholding and resumption, we feel our series supports brief (7-48 hours) periprocedural interruption of anticoagulation with subsequent resumption without increasing the risk of bleeding adverse events from EUS-GBD.
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