EUS-guided gallbladder drainage vs. percutaneous gallbladder drainage

Advances in self-expandable metal stents for endoscopic ultrasound-guided interventions

Endoscopic ultrasound (EUS)-guided interventions have evolved rapidly in recent years, with dedicated metal stents playing a crucial role in this process. Specifically, the invention of biflanged short metal-covered stents, including lumen-apposing metal stents (LAMS), and modifications in a variety of tubular self-expandable metal stents (SEMS), have led to innovations in EUS-guided interventions. LAMS or non-LAMS stents are commonly used in the EUS-guided drainage of pancreatic fluid collections, especially in cases of walled-off necrosis. Additionally, LAMS is commonly considered for drainage of the EUS-guided gallbladder or dilated common bile duct and EUS-guided gastroenterostomy. Fully or partially covered tubular SEMS with several new designs are being considered for EUS-guided biliary drainage. This review focuses on advances in SEMS for EUS-guided interventions and discusses related research results.

Assessment of Gallbladder Drainage Methods in the Treatment of Acute Cholecystitis: A Literature Review

Gallbladder drainage is a treatment option in high-risk surgical patients with moderate or severe acute cholecystitis. It may be applied as a bridge to cholecystectomy or a definitive treatment option. Apart from the simple and widely accessible percutaneous cholecystostomy, new attractive techniques have emerged in the previous decade, including endoscopic transpapillary gallbladder drainage and endoscopic ultrasound-guided gallbladder drainage. The aim of this paper is to present currently available drainage techniques in the treatment of AC; evaluate their technical and clinical effectiveness, advantages, possible adverse events, and patient outcomes; and illuminate the decision-making path when choosing among various treatment modalities for each patient, depending on their clinical characteristics and the accessibility of methods.

AGA Clinical Practice Update on Role of EUS-Guided Gallbladder Drainage in Acute Cholecystitis: Commentary

DESCRIPTION

Endoscopic gallbladder drainage is a feasible and efficacious alternative to percutaneous drainage in the management of acute cholecystitis for high-risk surgical candidates. Endoscopic ultrasound-guided gallbladder drainage and per-oral cholecystoscopy is facilitated by the use of lumen-apposing metal stents. Endoscopic ultrasound-guided gallbladder drainage should be performed by those expert in advanced therapeutic endoscopic ultrasound. Multidisciplinary collaboration between interventional radiology and surgery is paramount in the care of these patients. Choosing the optimal drainage method is dependent on individual patient characteristics.

METHODS

This commentary was drawn from a review of the literature to provide practical advice. Because this was not a systematic review, we did not perform any formal rating of the quality of evidence or strength of the presented considerations. This expert commentary was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer-review by the Clinical Practice Updates Committee and external peer-review through standard procedures of Clinical Gastroenterology and Hepatology.

Outcomes of EUS-guided transluminal gallbladder drainage in patients without cholecystitis

Background and Objectives:

Cholecystectomy is the gold standard for most gallbladder-related disease. However, many patients with gallbladder disease are poor surgical candidates. Current nonsurgical gallbladder drainage (GBD) methods include percutaneous cholecystostomy and endoscopic ultrasound-guided transluminal GBD (EUS-GBD). Outcomes for EUS-GBD for the treatment of noncholecystitis (NC) gallbladder disease have not been defined.

Materials and Methods:

Cases were identified using procedural data from a quaternary academic hospital for endoscopic procedures from 2015 to 2020. Patients who underwent EUS-GBD for acute cholecystitis, biliary colic, gallstone pancreatitis, and secondary prevention of gallstone disease were included.

Results:

Fifty-five cases of EUS-GBD were identified over the 5-year study period. Forty-one cases were performed for acute cholecystitis, and 15 were performed for other NC indications. Indications for NC drainage included primary treatment of symptomatic biliary colic and secondary prevention of gallstone pancreatitis and choledocholithiasis. There was no statistically significant difference in complications, mortality, or reintervention requirements. There was a 13.3% rate of immediate complications in the NC group, which were all medically managed.

Conclusions:

EUS-GBD appears to be a safe and effective way to manage gallstone disease in nonsurgical candidates with NC gallbladder-related disease. Overall complications and readmissions were infrequent. Complication rates were similar to those published in patients who underwent EUS-GBD for acute cholecystitis.

EUS guided gallbladder drainage

Cholecystectomy is the gold standard treatment for acute cholecystitis, but it may not be appropriate for patients with significant comorbidities. Percutaneous gallbladder drainage (PT-GBD) and endoscopic transpapillary gallbladder drainage (ET-GBD) are alternatives with good technical and clinical success rates, but are limited by technical challenges and the need for definitive therapy. EUS-guided gallbladder drainage (EUS-GBD) is quickly becoming the preferred modality of treatment at expert centers in this cohort of patients due to increased efficacy and minimal adverse events. Technicalities of the procedure, including selection of access site, should be informed by the ultimate needs and anatomy of each patient. With the evolution of new stents and accessories, including a cautery-enhanced lumen apposing metal stent deployment system, success rates and adverse events are favorable. A review of published case series demonstrates an overall clinical success rate of approximately 97% for EUS-GBD. The most common complication is pneumoperitoneum, so the evolution of self-expanding LAMS is promising. EUS-GBD has been successfully described in cases where definitive therapy or a bridge to cholecystectomy is needed. As the procedure's applications continue to evolve, there should be greater discussion about specific details including access site and stent selection.

How to perform EUS-based cholecystolithotomy

EUS-guided gallbladder drainage (EUS-GBD) is gradually emerging as an option for patients with cholecystitis. A stent-bridged endoscopic intervention in the gallbladder (GB) has been proposed. The formation of a fistulous tract after EUS-GBD facilitates the entry of the endoscope inside the GB to perform endoscopic lithotomy and polypectomy, which is an efficient and safe procedure. However, the technical aspects of this procedure in order to optimize the success rate have only been scarcely discussed. This paper discusses the EUS-GBD prepared for per-oral cholecystolithotomy, the stent indwelling time, the procedure, the devices of per-oral cholecystolithotomy and the follow-up. The recently published literature on this topic is also updated in this review.