Current Status of Endoscopic Gallbladder Drainage

Abstract

The gold standard for treatment of acute cholecystitis is laparoscopic cholecystectomy. However, cholecystectomy is often not suitable for surgically unfit patients who are too frail due to various co-morbidities. As such, several less invasive endoscopic treatment modalities have been developed to control sepsis, either as a definitive treatment or as a temporizing modality until the patient is stable enough to undergo cholecystectomy at a later stage. Recent developments in endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with endoscopic ultrasound EUS-specific stents having lumen-apposing properties have demonstrated potential as a definitive treatment modality. Furthermore, advanced gallbladder procedures can be performed using the stents as a portal. With similar effectiveness as percutaneous transhepatic cholecystostomy and lower rates of adverse events reported in some studies, EUS-GBD has opened exciting possibilities in becoming the next best alternative in treating acute cholecystitis in surgically unfit patients. The aim of this review article is to provide a summary of the various methods of gallbladder drainage GBD with particular focus on EUS-GBD and the many new prospects it allows.

Endoscopic ultrasonography-guided gallbladder drainage using lumen-apposing metal stents

“…While stents should ideally be removed after resolution of the underlying pathology, patients with multiple co-morbidities may not be ideal candidates for repeat endoscopic procedures. Few recent studies have reported longterm stenting to be safe [21]. In our personal experience in over 50 patients, there has seen no significant long term adverse event related to LAMS.…”

Initial experience with endoscopic ultrasound-guided gallbladder drainage.

“…Bearing in mind these recommendations, as well as the fact that 4 out of 5 of our patients had pancreatic cancer, and therefore had a short life expectancy, we decided against stent removal. This is also recommended by Chan and Teoh in patients with a short life expectancy [12].…”

“…These factors necessitate a search for new treatments in patients unfit for cholecystectomy. Recently, endoscopic ultrasound-guided gallbladder drainage (EUSGBD) has been gaining popularity [12–14]. The EUSGBD method consists in stent placement so as to create a permanent fistula connecting the gallbladder to the stomach or the duodenal bulb, thus enabling drainage of its contents to the gastrointestinal tract.…”

Safety and efficacy of endoscopic ultrasound‐guided gallbladder drainage combined with endoscopic retrograde cholangiopancreatography in the same session

“…Different endoscopic gallbladder drainage techniques have evolved in the last few years. Endoscopic transpapillary gallbladder drainage (ETGBD) eliminates the need for an external drain, with technical and clinical success rates comparable to PTGBD . However, it requires a high level of expertise in endoscopic retrograde cholangiopancreatography (ERCP), transcystic stenting may not be possible in patients with a tortuous or obstructed cystic duct with some series presenting technical success rates <90% and it shows a 20% relapse rate .…”

“…Endoscopic transpapillary gallbladder drainage (ETGBD) eliminates the need for an external drain, with technical and clinical success rates comparable to PTGBD . However, it requires a high level of expertise in endoscopic retrograde cholangiopancreatography (ERCP), transcystic stenting may not be possible in patients with a tortuous or obstructed cystic duct with some series presenting technical success rates <90% and it shows a 20% relapse rate . Development of lumen‐apposing metal stents (LAMS) specifically designed for transmural anastomosis allowed safe performance of endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) reducing the risk of pneumoperitoneum, bile leak and stent migration present when EUS‐GBD was carried out using other stents .…”