One-session endoscopic ultrasound-guided cholecystoduodenostomy for treatment of a high-surgical risk patient with symptomatic cholelithiasis of remnant gallbladder
Article information
Subtotal cholecystectomy is frequently performed in patients with acute cholecystitis and difficult anatomy.1 Symptomatic stones in the remnant gallbladder are an uncommon cause of post-cholecystectomy syndrome. Minimally invasive surgery includes laparoscopic and robot-assisted approaches; however, not all patients are candidates for severe fibrosis or high-risk clinical conditions.2 Endoscopic ultrasound-guided cholecystoduodenostomy (EUS-CD) represents a temporary alternative in high-risk patients with acute cholecystitis.3 However, stent removal and evaluation in other clinical scenarios, such as symptomatic cholelithiasis, have not been performed. Here, we present a case of EUS-CD in a high-risk surgical patient with symptomatic stones in the remnant gallbladder.
A 92 years-old patient with multiple comorbidities and a history of open subtotal cholecystectomy performed 29 years previously presented with intermittent right upper quadrant abdominal pain. Symptomatic cholelithiasis of the remnant gallbladder is confirmed. After discussing the potential therapeutic options, surgery was refused, and the endoscopic approach was accepted. A linear echoendoscope was introduced and a 15 mm gallstone in the 28×26 mm remnant gallbladder was identified. EUS-CD was performed using a 15×10 mm hot axios stent (Boston Scientific), and the stone was completely removed.
One-session stent extraction was performed because of the high probability of postsurgical fibrosis. Closure was performed using a mantis-like claw clip (Mantis clip; Boston Scientific). An hidrosoluble contrast study at 24-hours showed no leakage. A liquid diet was initiated and progressed to a soft and normal diet during the following week, and the patient was discharged after 5 days. Upper endoscopy at one month showed a remnant-placed clip in the duodenal bulb, and no clinical signs of abdominal pain were present during follow-up (Fig. 1, Video 1).
(A) A 15-mm stone was identified within a large remnant gallbladder. (B) Puncture of the remnant gallbladder with a 10×15 mm HotAxios stent through the duodenal bulb under fluoroscopic control. (C) Access through the cholecysto-duodenostomy. Lithotripsy and extraction of the stone with a basket was performed. (D, E) Same-session stent extraction was performed based on the high probability of postsurgical fibrosis between the gallbladder and the duodenal wall. (F) Full-thickness mucosal closure with mantis-like claw clips.
In conclusion, EUS-CD with same-session stent extraction represents an alternative treatment for symptomatic cholelithiasis of the remnant gallbladder in high-risk surgical patients.
Supplementary Material
Video 1.
One-session endoscopic ultrasound guided cholecystoduodenostomy for treatment of a high-surtgical risk patient with symptomatic cholelithiasis of remant gallbladder.
A video related to this article can be found online at https://doi.org/ce.2024.185.
Notes
Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.
Acknowledgments
Informed consent was obtained from the patient for publication of his information in this case.
Author Contributions
Conceptualization: OVHM, EMP; Data curation: EMP, JMHM; Software: JMHM; Formal analysis: OVHM; Supervision: OVHM, EM; Writing–original draft: OVHM; Writing–review & editing: all authors.