P1746 - Endoscopic Electrohydraulic Lithotripsy for a Large Gallbladder Stone, Through a Percutaneously Placed AXIOS Stent for Chronic Cholecystitis in a High Risk Surgical Patient

Nishit Patel, MD¹, Robert Reinhart, MD², Ellen Redstone, MD², Ayaz Matin, MD^3
1St. Luke's University Hospital, Easton, PA; ²St. Luke's Hospital, Bethlehem, PA; ³St. Luke's University Hospital, Bethlehem, PA

Introduction: The AXIOS stent is the first and currently the only stent indicated for transgastric and transduodenal endoscopic drainage of symptomatic chronic peri-pancreatic fluid under endoscopic ultrasound guidance. Its use for biliary drainage is under investigation. Treatment of choice for chronic cholecystitis is surgery, however for patients who are high risk candidates, chronic percutaneous cholecystostomy tube (PCT) with or without Endoscopic Electrohydraulic Lithotripsy (EHL) is recommended.

Case Description/Methods: An 81 year old female with 8 month history of chronic cholecystitis complicated by cholecystoduodenal fistula, & a large gallstone occluding the fistula resulting in recurrent cholangitis requiring ERCP with CBD stent and PCT; presented for outpatient followup. She was managed non-operatively with chronic PCT as she was a high risk surgical candidate. She was given multiple trials of PCT removal in the past but had failed. She complained of poor quality of life and significant local reactions to the PCT site and requested it be removed. After multi-disciplinary discussion between Interventional Radiology (IR) and advanced endoscopy team, it was felt feasible to percutaneously place an AXIOS stent through the existing cholecystoduodenal fistula to help facilitate the passage of bile into duodenum. Following this, she was given a trial of PCT removal but again presented with cholangitis soon after. This was complicated by intra-abdominal abscess requiring drainage. The mechanism for this was thought to be the ball-valving of the large gallstone seen previously, against the AXIOS stent obstructing the bile flow. Decision was made to pursue EHL through the indwelling AXIOS stent, to breakdown the stone to relieve the obstruction. The procedure was successful with complete removal of the stone. The AXIOS stent and in-situ CBD metal stent and chronic PCT were left in place. Following this patient significantly improved and was eventually discharged. On outpatient follow up, ERCP was repeated which showed clearance of CBD and AXIOS stent. Subsequently AXIOS stent and CBD stent were removed, however PCT was left in-situ. Patient continued to follow up outpatient with IR and was eventually given a capping trial of the PCT and continued to do well.

Discussion: Our case marks the first case where an AXIOS stent was used percutaneously and when EHL was performed through the AXIOS stent. This ultimately served as an alternative to surgery and possibly PCT in our high surgical risk patient.


Disclosures:
Nishit Patel indicated no relevant financial relationships.
Robert Reinhart indicated no relevant financial relationships.
Ellen Redstone indicated no relevant financial relationships.
Ayaz Matin indicated no relevant financial relationships.


Nishit Patel, MD¹, Robert Reinhart, MD², Ellen Redstone, MD², Ayaz Matin, MD³. P1746 - Endoscopic Electrohydraulic Lithotripsy for a Large Gallbladder Stone, Through a Percutaneously Placed AXIOS Stent for Chronic Cholecystitis in a High Risk Surgical Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.