Introduction:
Endoscopic ultrasound-guided gallbladder drainage (EGBD) using lumen apposing metal stents (LAMS) has become a pivotal part of the management of acute cholecystitis in patients who are not surgical candidates. Whilestudies have shown that EGBD is safe and effective in the acute setting, there is limited data on long term outcomes of patients undergoing EGBD. The decision to leave the LAMS in place indefinitely or schedule routine removal remains controversial, with varied practice patterns amongst endoscopists. We aimed to evaluate clinical outcomes of patients who had undergone EGBD with and without LAMS removal and had at least 1-year of follow-up.

Methods:
Multicenter retrospective analysis of all patients at 4 US medical centers who underwent EGBD with LAMS placement and had a minimum follow-up of 1 year. Patient demographics, indication for procedure, procedural characteristics, adverse events, and duration of follow-up were recorded. Where applicable, data were analyzed by mean and standard deviation and presented as percentages. The study was approved by the local Institutional Review Board.

Results:
Between four centers, a total of forty patients who underwent EGBD with LAMS placement had a follow-up of at least 1 year. 53% were female and the mean age was 66.8 years (SD 13.5). The most common indications for EGBD were acute calculous cholecystitis (11 cases, 27.5%) and malignancy related cholecystitis (9 cases, 22.5%). Additional indications are summarized in Table 1.
Clinical success, defined as successfully treating the indication for the procedure was achieved in 37 cases (92.5%). The LAMS was removed in 24 patients (60%). Mean time between LAMS placement and removal was 75 days (range 18 – 841 days). In all patients with LAMS removed, there were no adverse events at the time of removal or within 14 days of removal. In the 24 patients with LAMS removal, 7 patients (29.2%) experienced an adverse event including 5 total hospital admissions, 5 total endoscopic procedures, 2 biliary sepsis and 1 recurrent cholecystitis. In the 16 patients who did not have their LAMS removed, 9 patients (56.3%) experienced an adverse event including 7 total hospital admissions, 6 total endoscopic procedures and 1 recurrent cholecystitis. No patients experienced LAMS migration. The mean duration of follow-up was 453 days (SD 96) for the indwelling LAMS group and 576 days (SD 205) for the LAMS removal group.

Conclusions:
Our multicenter study evaluated outcomes of EGBD in patients with a minimum follow-up duration of 1 year. Our data suggests that rates of adverse events may be higher in the indwelling LAMS group (56.3%) as compared to the LAMS removal group (29.3%, mostly driven by need for gallbladder LAMS related repeat procedures or gallbladder LAMS related hospital admissions.

Nicholas McDonald

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