GASTROENTEROLOGY OUTPATIENT PROCEDURE NOTE
Procedure: Endoscopic Ultrasound (EUS)
Indication: Acute cholecystitis, EUS-guided gallbladder drainage
ASA Grade: III
Medications: General Anesthesia
Extent of Exam: Esophagus, stomach, duodenum, and adjacent structures.
Technique:
After obtaining informed consent, the scope was passed under direct vision.
Throughout the procedure, the patient?s blood pressure, pulse, and oxygen
saturations were monitored continuously. The echoendoscope was then advanced
into the esophagus, stomach, and duodenum to evaluate the luminal tract as
well as the adjacent structures on ultrasound. The procedure was performed
without difficulty. The patient tolerated the procedure well.
Endoscopic Findings:
Esophagus: Normal mucosa.
Stomach: Normal mucosa.
Duodenum: Few small superficial ulcerations in the second portion.
Unremarkable mucosa in the bulb.
Endosonographic (EUS) Findings:
The celiac artery was unremarkable.
The visualized portion of the left liver lobe appeared normal on
endosonographc examination without obvious mass lesions or cysts noted.
The pancreas parenchyma was unremarkable.
The pancreatic duct was not dilated.
The common bile duct was not dilated and a CBD stent was visualzied.
The gallbladder revealed sludge and stones with a mildly thickened wall.
Decision was made to pursue EUS-guided gallbladder drainage.
The gallbladder had the best visualization from the duodenal bulb. After a
good window was found, doppler imaging was used to ensure no interposing
vessels were noted. A 19g Olympus EZ Shot FNA needle was used to aspirate the
gallbladder and for confirmation.
The electrocautery-enhanced 10mm x 10mm Boston Scientific AXIOS lumen-apposing
metal stent (LAMS) was advanced through the working channel to the tip of the
scope. Again, doppler imaging was used to ensure no interposing vessels. After
a safe window was confirmed and stable/good positioning noted on fluoroscopy,
the catheter was advanced using electrocautery through the wall of the
duodenal bulb and gallbladder walls on ultrasound guidance creating a stoma.
The distal flange was deployed under ultrasound-guidance in the gallbladder
lumen and then a 0.035" x 450cm guidewire was immediately secured in the
gallbladder. Subsequently, the proximal flange was deployed under endoscopic
guidance within the duodenal bulb lumen.
Immediately upon LAMS deployment, a large amount of pus was draining into the
duodenum. With the guidewire left in place, the echoendoscope was exchanged
for a dual channel gastroscope. Pus was collected and sent for microbiology.
Under endoscopic and fluoroscopic guidance, one 7Fr x 5cm double pigtail
achoring plastic stent was placed with one end in the gallbladder lumen,
across the cholecysto-duodenal fistula, and one end in the distal stomach.
Contrast was injected to confirm placement of stent.
The scope was withdrawn.
Complications: None
Estimated blood loss from procedure: None
Impression:
- Successful EUS-guided gallbladder drainage via creation of a cholecysto-
duodenal fistula from the duodenal bulb utilizing a 10mm x 10mm LAMS anchored
with a 7Fr x 5cm double pigtail stent. Gallbladder pus collected and sent for
microbiology.
Procedure: Endoscopic Ultrasound (EUS)
Indication: Acute cholecystitis, EUS-guided gallbladder drainage
ASA Grade: III
Medications: General Anesthesia
Extent of Exam: Esophagus, stomach, duodenum, and adjacent structures.
Technique:
After obtaining informed consent, the scope was passed under direct vision.
Throughout the procedure, the patient?s blood pressure, pulse, and oxygen
saturations were monitored continuously. The echoendoscope was then advanced
into the esophagus, stomach, and duodenum to evaluate the luminal tract as
well as the adjacent structures on ultrasound. The procedure was performed
without difficulty. The patient tolerated the procedure well.
Endoscopic Findings:
Esophagus: Normal mucosa.
Stomach: Normal mucosa.
Duodenum: Few small superficial ulcerations in the second portion.
Unremarkable mucosa in the bulb.
Endosonographic (EUS) Findings:
The celiac artery was unremarkable.
The visualized portion of the left liver lobe appeared normal on
endosonographc examination without obvious mass lesions or cysts noted.
The pancreas parenchyma was unremarkable.
The pancreatic duct was not dilated.
The common bile duct was not dilated and a CBD stent was visualzied.
The gallbladder revealed sludge and stones with a mildly thickened wall.
Decision was made to pursue EUS-guided gallbladder drainage.
The gallbladder had the best visualization from the duodenal bulb. After a
good window was found, doppler imaging was used to ensure no interposing
vessels were noted. A 19g Olympus EZ Shot FNA needle was used to aspirate the
gallbladder and for confirmation.
The electrocautery-enhanced 10mm x 10mm Boston Scientific AXIOS lumen-apposing
metal stent (LAMS) was advanced through the working channel to the tip of the
scope. Again, doppler imaging was used to ensure no interposing vessels. After
a safe window was confirmed and stable/good positioning noted on fluoroscopy,
the catheter was advanced using electrocautery through the wall of the
duodenal bulb and gallbladder walls on ultrasound guidance creating a stoma.
The distal flange was deployed under ultrasound-guidance in the gallbladder
lumen and then a 0.035" x 450cm guidewire was immediately secured in the
gallbladder. Subsequently, the proximal flange was deployed under endoscopic
guidance within the duodenal bulb lumen.
Immediately upon LAMS deployment, a large amount of pus was draining into the
duodenum. With the guidewire left in place, the echoendoscope was exchanged
for a dual channel gastroscope. Pus was collected and sent for microbiology.
Under endoscopic and fluoroscopic guidance, one 7Fr x 5cm double pigtail
achoring plastic stent was placed with one end in the gallbladder lumen,
across the cholecysto-duodenal fistula, and one end in the distal stomach.
Contrast was injected to confirm placement of stent.
The scope was withdrawn.
Complications: None
Estimated blood loss from procedure: None
Impression:
- Successful EUS-guided gallbladder drainage via creation of a cholecysto-
duodenal fistula from the duodenal bulb utilizing a 10mm x 10mm LAMS anchored
with a 7Fr x 5cm double pigtail stent. Gallbladder pus collected and sent for
microbiology.