Endoscopic transduodenal drainage of the gallbladder

Background: Acute cholecystitis is a common surgical disease that is definitively managed with open or laparoscopic cholecystectomy. Patients presenting with moderate or severe cholecystitis and significant comorbid conditions precluding surgery typically require urgent gallbladder drainage via percutaneous cholecystostomy tube (PCT). Recently, endoscopic gallbladder drainage (EUS-GBD) with placement of a transduodenal metal lumen-apposing stent has emerged as a potential alternative strategy to PCT. Technique: A linear array echoendoscope is used to identify an appropriate puncture site in the duodenal bulb to access the gallbladder neck or body. Once color duplex confirms the lack of vascular structures in the planned pathway, a needle-knife catheter with electrocautery is inserted into the gallbladder under endoscopic ultrasound guidance. Entry is confirmed by aspiration of bile and contrast injected under fluoroscopy. A guidewire is advanced through the needle, the tract is dilated, and a lumen-apposing, self-expanding metal stent (Xlumena, Mountain View, CA) is advanced over the guidewire to establish a cholecystoduodenal fistula (See Figure). Application: Patients with moderate to severe cholecystitis who are deemed poor candidates for operative management and PCT after interdisciplinary evaluation by surgeon and therapeutic endoscopist may be candidates for this technique. 5 Patients underwent EUS-GBD with contraindications to cholecystectomy and PCT including a combination of coagulopathy or need for anticoagulation (3), chronic kidney disease (2), congestive heart failure (2), dementia (2), advanced malignancy (2), and severe COPD (1). Results: 5 Patients underwent this procedure at our institution with 100% technical and clinical success of gallbladder drainage with no peri-procedural or disease-specific deaths. [Stent]