Elective endoscopic gallbladder treatment in patient with recurrent gallbladder colic and high surgical risk

An 80-year-old woman presented with a 1-year history of recurrent right upper quadrant colicky pain. Her medical history included abdominal surgery, ischemic stroke with impaired mobility, and obesity (body mass index > 30.1 kg/cm²).

Transabdominal ultrasound showed distended gallbladder with thickened walls and two large stones (4 cm and 3 cm). Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) followed by intracholecystic lithotripsy was offered as a minimally invasive treatment alternative to surgery and scheduled for 2 weeks later.

EUS examination confirmed gallbladder wall thickening and two large stones ([Video 1]). Transduodenal EUS-GBD using a 15 × 10 mm AXIOS stent (Boston Scientific, Marlborough, Massachusetts, USA) mounted onto a cautery device was successfully performed ([Fig. 1]). After 48 hours, the central stent was dilated up to 15 mm and the gallbladder lumen accessed with a gastroscope. After adequate water irrigation, holmium laser lithotripsy with variable pulse power and frequencies was performed [1], and fragmented stones were flushed out or removed using a Dormia basket or Roth net until complete gallbladder clearance was achieved ([Fig. 2]). No adverse events occurred and the patient was discharged.

Video 1 Endoscopic view of holmium laser lithotripsy of the central part of one of the stones inside the gallbladder.

Fig. 1 Endoscopic ultrasound view of the distal flange of the AXIOS stent (Boston Scientific, Marlborough, Massachusetts, USA) opened inside the gallbladder after pushing one of the stones forward.

Fig. 2 Endoscopic view of holmium laser lithotripsy of the stone fragments inside the gallbladder.

Outpatient cholecystoscopy 2 weeks later revealed complete gallbladder clearance. The stent was removed using a grasping forceps ([Fig. 3]) and exchanged for two double-pigtail stents (7 Fr, 4 cm), which were left in place ([Fig. 4]).

Fig. 3 Endoscopic view of the gastric side of the fistulous tract after removal of the AXIOS stent (Boston Scientific, Marlborough, Massachusetts, USA).

Fig. 4 Endoscopic view of the two double-pigtail stents placed from the stomach into the gallbladder through the fistulous tract.

Elective endoscopic gallbladder treatment has been described previously in five relatively young patients with a mean age of 50 years and giant gallstones, who rejected surgery and desired gallbladder preservation [2]. With an aging population, the number of elderly frail individuals at high surgical risk and gallstone disease requiring surgical intervention is expected to increase [3], and elective endoscopic gallbladder treatment may be a valid alternative treatment option in such patients.

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Publikationsverlauf

Artikel online veröffentlicht:
17. September 2021

• References

• 1 Larghi A, Rimbas M, Attili F. et al. Endoscopic holmium laser lithotripsy of symptomatic gallstones through a lumen-apposing self-expandable metal stent. Am J Gastroenterol 2016; 111: 1516
• 2 Wang W, Liu B, Qi K. et al. Efficacy and safety of endoscopic laser lithotripsy and lithotomy through the lumen-apposing metal stent for giant gallbladder stones. VideoGIE 2020; 5: 318-323
• 3 Chhoda A, Mukewar SS, Mahadev S. Managing gallstone disease in the elderly. Clin Geriatr Med 2021; 37: 43-69