Feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients unsuitable for cholecystectomy

doi:10.1016/j.gie.2011.03.1120

Gastrointestinal Endoscopy

Volume 74, Issue 1, July 2011, Pages 176-181

https://doi.org/10.1016/j.gie.2011.03.1120 Get rights and content

Background

Although early laparoscopic cholecystectomy is the treatment of choice for patients with acute cholecystitis, percutaneous cholecystostomy has been performed in patients unsuitable for cholecystectomy. EUS-guided transgastric/transduodenal gallbladder drainage by using a plastic stent and/or nasobiliary drainage may be an alternative effective treatment for these patients, but bile leakage into the peritoneal space causing bile peritonitis is not uncommon during placement of a plastic stent.

Objective

To evaluate the technical feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent (CSEMS) in patients with acute cholecystitis who are unsuitable for cholecystectomy.

Design

Prospective feasibility study.

Setting

Tertiary-care referral center.

Patients

This study involved 15 patients with acute cholecystitis who did not respond to initial medical treatment and were unsuitable for cholecystectomy.

Intervention

EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified CSEMS.

Main Outcome Measurements

Technical success, functional success, complications associated with the placement of a metal stent, and recurrence of acute cholecystitis.

Results

Modified CSEMSs were successfully placed in all patients through the stomach (n = 10) or duodenum (n = 5). All patients achieved functional success within 3 days of metal stent placement. Pneumoperitoneum occurred in two patients during or after the procedure, but both patients improved with conservative management. During follow-up (median 145 days, range 60-297 days), no patient experienced recurrent cholecystitis.

Limitations

Small patient population without long-term follow-up.

Conclusion

Placement of a modified CSEMS after EUS-guided transgastric/transduodenal gallbladder drainage may be a feasible and safe alternative to treatments such as percutaneous cholecystostomy in patients with acute cholecystitis who are unsuitable for cholecystectomy.

Section snippets

Patients

Between January 2010 and October 2010, 15 patients in our institution underwent EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified CSEMS. Patients were included if they had acute cholecystitis with advanced malignancy or poor surgical performance (American Society of Anesthesiologists Physical Status Classification System score of IV or V).⁷ Acute cholecystitis was diagnosed according to the Tokyo guidelines, including a combination of typical

Patient characteristics

The 15 patients included 6 men and 9 women, mean age 74 years (range 58-86 years), who had acute cholecystitis and were unsuitable for cholecystectomy. Eight patients had advanced malignancies, and the other 7 had American Society of Anesthesiologists Physical Status Classification System scores ≥IV. Nine patients had calculous cholecystitis; 6 had acalculous cholecystitis. The thickness of the gallbladder wall was 6.6 mm on average (range 2.6-10.2 mm) (Table 1).

Technical success

A modified CSEMS was

Discussion

Development of the large-channel linear array echoendoscope has resulted in the description of various innovative diagnostic and therapeutic procedures.9, 10 Several case reports have described EUS-guided biliary and pancreatic duct puncture and drainage, in place of the conventional percutaneous approach.11, 12 To date, however, only a few case reports and case series have described EUS-guided gallbladder drainage, and the methodology and devices relevant to such drainage have not yet been

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There are more references available in the full text version of this article.

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EUS-guided gallbladder drainage (EUS-GBD) with lumen-apposing metal stents (LAMSs) has been reported as a rescue treatment with encouraging results for the relief of jaundice in patients with distal malignant biliary obstruction (DMBO) and after failure of both ERCP and EUS-guided choledochoduodenostomy.
This was a multicenter retrospective analysis of all cases of consecutive EUS-GBD with LAMSs used as a rescue treatment for patients with DMBO in 14 Italian centers from June 2015 to June 2020. Primary endpoints were technical and clinical success, whereas the secondary endpoint was the adverse event (AE) rate.
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Our study shows that EUS-GBD with LAMSs used as a rescue treatment for patients affected by DMBO represents a valuable option in terms of technical and clinical success rates, with an acceptable AE rate. To the best of our knowledge, this is the largest study concerning the use of this procedure. (Clinical trial registration number: NCT03903523.)
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Acute cholecystitis (AC) is a very common disease in clinical practice. Laparoscopic cholecystectomy remains the gold standard treatment for AC, however due to aging population, the increased prevalence of multiple comorbidities and the extensive use of anticoagulants, surgical procedures may be too risky when dealing with patients in emergency settings. In these subsets of patients, a mini-invasive management may be an effective option, both as a definitive treatment or as bridge-to-surgery. In this paper, several non-operative treatments are described and their benefits and drawbacks are highlighted. Percutaneous gallbladder drainage (PT-GBD) is one of the most common and widespread techniques. It is easy to perform and has a good cost/benefit ratio. Endoscopic transpapillary gallbladder drainage (ETGBD) is a challenging procedure that is usually performed in high volume centers by expert endoscopists, and it has a specific indication for selected cases. EUS-guided drainage (EUS-GBD) is still not widely available, but it is an effective procedure that could have several advantages, especially in rate of reinterventions. All these treatment options should be considered together in a stepwise approach and addressed to patients after an accurate case-by-case evaluation in a multidisciplinary discussion. In this review, we provide a possible flowchart in order to optimize treatments, resource and provide to patients a tailored approach.
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Citation Excerpt :
A recent meta-analysis of EUS-GBD demonstrated pneumoperitoneum and bile leakage as the most common AEs in the procedure, which may potentially be caused by tract dilation and the placement of small diameter plastic stents. The use of self-expanding LAMS is, therefore, recommended to minimize tract dilation and reduce the risks of bile leakage and stent migration.37,40 Another meta-analysis consisting of 8 studies with 393 patients evaluated AEs with LAMS in EUS-GBD.47
Acute cholecystitis: Which is the best therapeutic option?
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: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

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New methodClinical endoscopyFeasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients unsuitable for cholecystectomy

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Patients

Patient characteristics

Technical success

Discussion

Am J Surg

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

New method
Clinical endoscopy
Feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients unsuitable for cholecystectomy