Post written by Mauro Manno, MD, from the Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Carpi, Italy.

EUS-guided gallbladder drainage with a lumen-apposing metal stent (LAMS) is a viable treatment option for acute cholecystitis and an alternative to cholecystectomy in patients at high risk for surgery.

However, recurrent acute cholecystitis with stone impaction in the LAMS can subsequently occur in patients with large calculi. We report the video case of a patient with recurrent acute cholecystitis and a 15-mm stone impacted in the distal flange of a previously placed LAMS that we treated successfully with endoscopic electrohydraulic lithotripsy (EEHL).

Our case shows how to manage a severe adverse event related to EUS-guided gallbladder drainage with a LAMS endoscopically, without the need for surgery. EUS-guided gallbladder drainage in patients deemed unfit for surgery is an effective and safe technique.

Yet, stone impaction and LAMS obstruction can subsequently occur. In this case, EEHL–upon generating high-amplitude hydraulic pressure waves with repetitive pulses of energy to create a mechanical shockwave–can be used successfully to fragment the impacted stone.     

Endoscopic cholecysto-gastrostomy with a LAMS is an effective rescue therapy that can be used in patients unfit for surgery. Unfortunately, subsequent stone impaction in the previously placed LAMS may occur.

We believe that it is important to illustrate how to successfully manage this adverse event endoscopically, especially as surgery is best avoided in frail patients who are candidates for EUS-guided gallbladder drainage because of high surgical risk.

Endoscopic view of partially buried lumen-apposing metal stent (A) with the lumen obstructed by an impacted biliary stone (B), confirmed by fluoroscopic imaging (C).

Read the full article online.

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