Endoscopic management of food impaction following endoscopic ultrasound-guided gallbladder drainage using lumen-apposing metal stent

A 61-year-old man was referred to our center for severe acute cholecystitis. Given his serious comorbidities (previous dissection of an aortic aneurysm with residual disease awaiting surgical reintervention; stage 3b chronic kidney disease; alcohol-related liver disease), the patient underwent transgastric endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a 10 × 10 mm lumen-apposing metal stent (LAMS) ( Fig. 1 ). In the following months the patient experienced two episodes of food impaction of LAMS, which were treated endoscopically with placement of two double-pigtail plastic stents coaxially through the LAMS. Then, 3 months after the procedure, the patient was admitted for a third recurrence of acute cholecystitis. Computed tomography revealed a distended gallbladder, 19 cm in the long axis and completely occupied by food ( Fig. 2 ). After a multidisciplinary evaluation, surgery was again excluded, and an endoscopic attempt was performed.

Fig. 1.

 Lumen-apposing metal stent placement (red arrow) for transantral gallbaldder drainage.

Fig. 2.

 Computed tomography image of food impaction within the gallbladder (red arrow).

The double-pigtail plastic stents and the obstructed LAMS were removed to gain access to the gallbladder, which was filled with food residue. The EndoRotor system (Micro-Tech Endoscopy, Ann Arbor, Michigan, USA) was used to simultaneously fragment and aspirate the impacted food ( Fig. 3 ), resulting in removal of at least 600 mL of fragmented material ( Fig. 4 ). The procedure was completed using polypectomy snares and retrieval nets ( Fig. 5 ). Two double-pigtail plastic stents were placed through the fistulous tract ( Video 1 ). No immediate adverse events occurred, and after 3 months’ follow-up there was no recurrence of acute cholecystitis.

Fig. 3.

 Endoscopic removal of food content from the gallbladder using the EndoRotor system (Micro-Tech Endoscopy, Ann Arbor, Michigan, USA).

Fig. 4.

 Material removed using the EndoRotor system (Micro-Tech Endoscopy, Ann Arbor, Michigan, USA).

Fig. 5.

 Endoscopic removal of food content from the gallbladder with a retrieval net.

Video 1  Endoscopic management using the EndoRotor system (Micro-Tech Endoscopy, Ann Arbor, Michigan, USA) for cholecystic food impaction following endoscopic ultrasound-guided gallbladder drainage.

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EUS-GBD using LAMS is an effective treatment option for acute cholecystitis in fragile patients ¹ . However, food impaction can lead to recurrence of acute cholecystitis and its management can be challenging ² . The ability of EndoRotor to fragment and collect solid and semisolid material may therefore be an effective option beyond its use in gastrointestinal neoplastic lesion resection and necrosectomy of walled-off pancreatic necrosis ^{3 4 5} .

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