Endoscopic ultrasonography guided-gallbladder stenting and interventions

Anthony Y Teoh, FRCSEd, Gen, Philip W Chiu, FRCS, Ed, Enders K Ng, FRCS, Ed. Prince of Wales Hospita, Chinese University of Hong Kong.

Objective
The use of endoscopic methods to treat acute cholecystitis or gallbladder stones has been described in the past but did not gain widespread popularity. A new lumen apposing stent (AXIOS, Xlumena, CA, USA) designed for EUS guided-transmural gallbladder stenting (EUS-GBS) has become available and we describe our experience of EUS-GBS and the associated gallbladder interventions that were possible through the stent.

Methods
We recruited patients  who suffered  were on long-term cholecystomies (PTC) and unfit for surgery. EUS-GBS was performed with a linear array echoendoscope. The gallbladder was punctured from the dudoenum or antrum with a 19-gauge needle. A 0.025" guidewire was then inserted and the track and looped in the gallbladder. The track was then dilated with the cystotome, needle knife and a 4 or 6 mm biliary balloon. The AXIOS stent was then inserted and deployed under EUS and endoscopic guidance. Follow-up oesophagogastroduodenoscopy (OGD) was performed 3 months after the procedure. In addition to visual confirmation, clearance of stones was confirmed with a cholecystrogram. Any residue stones were removed with laser lithotripsy and magnifying NBI cholecytoscopy of the gallbladder mucosa was performed. Biopsy of the gallbladder mucosa was performed to correlate the histology with the findings on NBI cholecystoscopy. The stent was then removed if cholecystoscopy showed no residue stones. 

Results 
In this video, we demonstrated our technique of EUS-GBS in one patient with acute cholecystitis and one on long-term cholecystostomy. A total of 4 patients on long-term PTC’s were recruited between June 2012 and September 2013. The mean (S.D.) age of the patients was 82.5 (7.23) years old. Technical success and clinical success was achieved on all patients. The mean (S.D.) procedural time was 35.5 (11.4) minutes. Procedural complications occurred in 1 patient with pneumoperitoneum and settled conservatively. Follow-up cholecystoscopy was performed in all patients and 1 patient had residue stones that required laser lithotripsy. The video showed the performance of cholecystoscopy through the stent, followed by laser lithotripsy of a gallstone, NBI examination and correlation with histological assessment.

Conclusions
EUS guided-gallbladdder stenting and intervetions were feasible with the lumen apposing stent. It is a technically demanding procedure requiring dedicated instruments. Further studies with larger sample sizes are required to further define the efficacy of the procedure.

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