GALLBLADDER PERFORATION DURING ENDOSCOPIC INTERNALIZATION OF PERCUTANEOUS CHOLECYSTOSTOMY TUBE – LESSONS LEARNED

Introduction
Nonsurgical management options for acute cholecystitis include percutaneous or endoscopic gallbladder drainage . Here we describe a case of internalization of percutaneous cholecystostomy tube (PCT) conversion to endoscopic ultrasound guided gallbladder drainage (EUS-GBD), which was complicated by gallbladder perforation during distention of the gallbladder lumen, ultimately necessitating laparotomy.

Case description
An 80-year-old male with a history of coronary artery disease with previous coronary artery bypass surgery, recurrent deep venous thrombosis on anticoagulation, and chronic obstructive pulmonary disease on oxygen presented with AC. The patient was evaluated by general surgery and deemed to be high risk for surgery and underwent interventional radiology (IR) guided percutaneous cholecystostomy tube (PCT) placement. Patient had resolution of clinical symptoms. Subsequently, patient was referred to our advanced endoscopy service for consideration of internalization of PCT. After discussion in multidisciplinary conference, decision was made to proceed with EUS-GBD. Given the gallbladder was decompressed by the PCT, it was distended by infusion of mixture of saline and contrast. The fluid mixture was connected to the endoscope water irrigation pedal and about 75 cc of the fluid was infused. Appropriate distention of gallbladder lumen was seen and a free hand 10 mm by 10 mm lumen apposing metal stent (LAMS) was placed under EUS guidance from the duodenal bulb. Stones and bilious fluid were seen in the duodenum, confirming appropriate position of LAMS. However, patient had severe pain after the procedure and underwent a computed tomography (CT) scan which showed findings consistent with gallbladder perforation and spillage of several stones into the peritoneum, despite appropriate position of LAMS.
General surgery was consulted and patient was taken for laparotomy with intra-abdominal washout, cholecystectomy, removal of LAMS and closure of duodenal defect. On histopathological specimen, only one defect was seen in the gallbladder wall at the level of the PCT suggesting the gallbladder perforation occurred due to rapid filling of the gallbladder lumen with a high-pressure endoscope water jet rather than overdistention [Figure 1,2]. Our hypothesis is that increased pressure of fluid infusion allowed for expansion of the PCT entry point into the gallbladder wall leading to spillage of bile and gallstones.


Conclusions
Our case highlights that during endoscopic internalization of the PCT, the gallbladder lumen should not be infused with fluid under high pressure to avoid transient increase in size of the entry point of the PCT into the gallbladder wall leading to adverse events. Endoscopists should be mindful of this mechanism of gallbladder perforation during endoscopic internalization of PCT.