S5217 Cholecystocolonic Fistula: A Rare Late Complication Following EUS-Guided GB Drainage

Introduction: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as a safe, effective, and minimally invasive alternative to surgical cholecystectomy, percutaneous drainage, and endoscopic transpapillary GBD in patients with acute cholecystitis. The invention of the lumen-apposing metal stent (LAMS), and more recently, FDA approval of single-step EUS-guided LAMS delivery systems, have made EUS-GBD simpler and safer. Although this technique has been widely accepted by the interventional endoscopy community, contraindications, potential adverse events, and late complications should be thoroughly discussed prior to the procedure, especially with surgically unfit patients. Case Description: The patient was a 69-year-old man with medical history of metastatic adenocarcinoma of the cecum status post-right hemicolectomy followed by radiation and chemotherapy with a history of EUS-guided gallbladder (GB) drainage with successful placement of 10 mm × 10 mm LAMS and an additional 7 Fr × 5 cm coaxial plastic stent placed across LAMS into the GB to prevent stent migration, clogging, and allow adequate biliary drainage. He now presented with worsening of right upper quadrant and right lower quadrant abdominal pain associated with chills. Imaging findings showed multiple foci of gas within gallbladder with frothy secretion appearance, and some pericholecystic inflammatory fat stranding. Esophagogastroduodenoscopy and colonoscopy were performed and occlusion of the cholecystoduodenostomy was excluded. The colonoscopy showed erosion of the double pigtail plastic stent from the GB into the colonic lumen. The stent was removed with raptor forcep and fistulous tract was closed with over-the-scope clip. Follow up computed tomography abdomen with contrast showed no evidence of contrast extravasation and decrease in the amount of gas and fluid within GB lumen. Patient was discharged home on antibiotic therapy. Discussion: EUS-GBD is a relatively safe procedure, with minimal complications in expert hands. Stent migration, displacement, or maldeployment is the most dreaded complication of EUS-GBD. Although there is no formal recommendation on the coaxial pigtail stent placement, many experts prefer an additional barrier to prevent LAMS migration, occlusion, and to allow adequate GB drainage. Given lack of evidence offering long-term advantage of coaxial pigtail placement across LAMS and possibility of pigtail erosion into the adjacent viscera, particularly when the GB is collapsed, the necessity and timely removal of pigtail should be considered in the future.