Efficacy and safety of endoscopic laser lithotripsy and lithotomy through the lumen-apposing metal stent for giant gallbladder stones

Abstract

Background and aims: EUS-guided gallbladder drainage has been increasingly applied for acute cholecystitis in high-risk surgical patients. In cases of EUS-guided gallbladder drainage with lumen-apposing metal stents (LAMSs), endoscopic retrieval of gallstones becomes feasible. However, retrieval of giant gallstones is still difficult because of the limited space in the saddle section of the LAMS. In this study, we aimed to evaluate the efficacy and safety of endoscopic laser lithotripsy and lithotomy through LAMSs for the removal of giant gallstones.

Methods: Five consecutive patients with recurrent cholecystitis due to giant gallstones were enrolled. We proceeded with EUS-guided LAMS implantation. Endoscopic laser lithotripsy and lithotomy then was performed through the LAMSs, and the stents were removed after all stones were extracted. The patients were followed up at scheduled times.

Results: EUS-guided LAMS implantation was successfully performed, and target gallstones were completely removed in all 5 patients. There was no severe bleeding, perforation, or stent migration during the operation. No recurrence of gallstones was found at late follow-up.

Conclusions: Endoscopic laser lithotripsy and lithotomy through LAMSs could be a safe and effective approach for removal of giant gallstones.

Keywords: ELLL, endoscopic laser lithotripsy and lithotomy; LAMSs, lumen-apposing metal stents.

Figure 1

EUS-guided lumen-apposing metal stent implantation. A, EUS-guided puncture and irrigation of the gallbladder. B, A guidewire was advanced into the gallbladder through the needle. C, Imaging showed the gallstone. D, Successful deployment of the stent under EUS and fluoroscopic guidance. E, Gastroscopy showing the gallstone through the stent. F, CT image showing the stent in good position.

Figure 2

Endoscopic laser lithotripsy and lithotomy through the lumen-apposing metal stents. A-C, The giant gallstones were broken into fragments by laser. D, Minor hemorrhage occurred during laser lithotripsy. E-G, The fragments were extracted by baskets, disposable bags, and rat-tooth forceps, respectively. H, I, Gastroscopy and biopsy were performed for potential mucosal lesions.

Figure 3

Healing condition of the artificial fistulas after stent removal. A, B, The fistula closed 3 days after stent removal in case 2. C-E, The fistula had not closed spontaneously 3 days after stent removal, and endoclips were used to promote closure in case 3. F, The fistula nearly closed 11 days after stent removal in case 3. G-I, The fistula was closed with endoclips immediately after stent removal and nearly closed 10 days later in case 4.