Endoscopic ultrasonography-guided gallbladder drainage

Key points

In patients who are unfit for surgery, percutaneous drainage, endoscopic transpapillary drainage and EUS-guided drainage are all effective and safe alternative procedures to cholecystectomy
EUS-guided drainage is preferred over percutaneous technique due to similar rates of technical success and reduced rates of reintervention and unplanned readmission
EUS-guided drainage is associated with a steeper learning curve and should be performed only in high-volume endoscopy centers where the requiste expertise is available.

Introduction

The gold standard for treatment of acute cholecystitis is laparoscopic cholecystectomy. However, the procedure is associated with a risk of postoperative complications in 13% to 20%, and a conversion rate to open surgery in 17% to 25% of patients. In patients that are unfit for cholecystectomy, percutaneous cholecystostomy is recommended for drainage of the gallbladder (PTGBD). However, in elderly patients, the procedure may be associated with a mortality rate of 16% and a morbidity rate of 47%. Furthermore, care of the external tube is frequently cumbersome for elderly patients. In order to avoid inconvenience and technical problems associated with presence of an external drainage tube, endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative treatment method. For successful transpapillary gallbladder drainage, the cystic duct needs to be cannulated and any stones obstructing the Hartman’s pouch need to be dislodged. Thus, the clinical success rates for the procedure vary between 62% and 89%. In addition, the stent needs to be periodically changed, and the procedure does not address existing gallstones thereby posing a risk for recurrent cholecystitis.

Recently, the technique of EUS-guided transmural gallbladder drainage (EGBD) has been described. The technique involves EUS-guided creation of a cholecystogastric or duodenal fistula and placement of a stent for gallbladder drainage. It was initially described in 2007 with transmural placement of a double pigtail plastic stent into the gallbladder for a patient with unresectable hilar cholangiocarcinoma and acute cholecystitis. The technique appears to be a viable alternative to PTGBD and ETGBD, as it precludes the need to cannulate the cystic duct or perform periodic stent exchanges and lacks the discomfort associated with presence of an external drainage tube. Furthermore, the large- diameter stent allows for endoscopic access to the gallbladder lumen for complete clearance of stones, thereby potentially reducing the risk of recurrent cholecystitis.

Indications for endoscopic ultrasonography-guided transmural gallbladder drainage

Currently, there are three main indications for EGBD. One, EGBD can be performed as an alternative to percutaneous drainage in patients who are at high risk for cholecystectomy ( Table 23.1 ). Two, EGBD can be performed in patients on long-term cholecystostomy drainage who desire conversion to internal drainage. Three, EGBD can be performed in patients suffering from malignant biliary obstruction where ERCP and EUS-guided biliary drainage have failed. ^, Presently, evidence for EGBD is derived mainly from patients suffering from acute cholecystitis who are unfit for surgery.

TABLE 23.1

Indications for EUS-Guided Gallbladder Drainage

Indications of EUS-Guided Gallbladder Drainage
1. High-risk surgical candidates suffering from acute cholecystitis 2. Failure to wean after long-term cholecystostomy drainage catheter placement 3. Palliation of malignant biliary obstruction in patients in whom ERCP and EUS-guided biliary drainage failed

Technical aspects of EUS-GBD

Choice of endoprosthesis

Initially, due to the lack of EUS-specific endoprosthesis, a variety of biliary accessories used at ERCP, such as double pigtail plastic or fully-covered metal stents and nasobiliary drainage catheters, had been adopted. Compared to PTGBD, EUS-guided gallbladder drainage (EUS-GBD) using nasocholecystic catheters demonstrated similar rates of technical (97% vs 97%) and clinical success (100% vs 96%). The median postprocedure pain score was significantly lower after EUS-GBD than with PTGBD. In a pilot study of eight surgically unfit patients treated with double pigtail plastic stents at EUS-GBD, technical success and clinical success were achieved in all patients; however, adverse events were encountered in three. No recurrence of acute cholecystitis was observed at a median follow-up of 186 days. It was postulated initially that this approach may be preferable for patients in whom a future cholecystectomy is contemplated. However, plastic stents tend to become easily occluded due to their narrow lumen. Although fully covered self-expandable metal stents have a larger lumen, they are not intended for transluminal drainage and hence do not possess tissue apposition properties. Although one of the preliminary studies demonstrated a technical and clinical success of 98%, adverse events were observed in 11% that included duodenal perforation, self-limiting pneumoperitoneum, distal stent migration, and cholecystitis due to stent occlusion. With the objective of overcoming the high incidence of observed adverse events, a dedicated stent with lumen-apposing properties was designed.

Lumen-apposing metal stents (LAMS) have a dumbbell-shaped configuration with wide flanges at either end for tissue apposition. They are also fully coated to prevent leakage of air and gastrointestinal contents. The silicone lining also impedes tissue ingrowth, making LAMS readily removable when indicated. The large lumen of these stents allows for quick and effective drainage of infectious material and allows for further transluminal interventions via the stent lumen. A range of diagnostic and interventional procedures can be performed through the stent lumen, such as magnifying endoscopy, laser lithotripsy, and basket mechanical lithotripsy. More recently, cautery-enhanced catheter systems have been developed. These include the Hot AXIOS (Boston Scientific, Marlborough, USA) and the Hot SPAXUS (Taewoong Medical Co, Gimpo, Korea). These stents allow for the option of direct puncture of the target organ thereby obviating the cumbersome steps of needle puncture, guidewire placement, device exchange, and hence minimizing the potential for adverse events such as bile leakage and incorrect stent deployment.

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