EUS-guided gallbladder drainage for acute cholecystitis

Percutaneous transhepatic gallbladder drainage (PT-GBD) is the most common, nonoperative method for gallbladder decompression in patients unfit for cholecystectomy. However, drain-related complications (20%-75%), including tube changes, dyscosmesis, discomfort, and recurrent cholecystitis (up to 15%), limit its long-term use. Endoscopic transpapillary gallbladder drainage (ET-GBD) and now, endoscopic ultrasound–guided gallbladder drainage (EUS-GBD), have emerged as options.

ET-GBD is performed at endoscopic retrograde cholangiopancreatography (ERCP) by cannulating the cystic duct, allowing placement of a pigtail plastic stent into the gallbladder. However, obstructing pathology (stone, stricture, metal stent or mass) may result in lower technical and clinical success when compared with EUS-GBD (84% vs. 98% and 91% vs. 97%, respectively). Furthermore, it does not allow for treatment of gallstones, and may require stent exchanges.

EUS-GBD involves placing a stent from the duodenum/stomach into the gallbladder under EUS guidance. Initial use of pigtail plastic stents and biliary self-expandable metal stents were not ideal, because of their risk of leakage, longer length (contralateral wall injury, occlusions), and migration (lack of flanges). Lumen-apposing metal stents (LAMS) overcame these limitations because of their short length and large flanges, and their large diameters (up to 20 mm) aid passage of gallstones or cholecystoscopy. Several case series and comparative trials have been published on EUS-GBD including a randomized prospective trial of EUS-GBD vs. PT-GBD demonstrating its superiority. Adverse events are uncommon and include misdeployments, bleeding, perforation, bile leaks, occlusion (commonly with food, prompting some endoscopists to place pigtails stents through the LAMS and avoiding the stomach as a target), and migration.

EUS-GBD should be avoided in patients who have a perforated gallbladder, have large volume ascites, or are too sick to tolerate anesthesia. Although there are patients who have subsequently undergone cholecystectomy post EUS-GBD, a discussion with one’s surgeon must be had prior to choosing this approach over ET-GBD.

In conclusion, determining the ideal method for endoscopic GBD in high-surgical-risk patients requires consideration of comorbidities, anatomy (GB position, cystic duct characteristics), presence of ascites, future surgical candidacy, and local expertise. ET-GBD should be prioritized for patients requiring ERCP for alternative reasons, large volume ascites, and as a bridge to cholecystectomy. Conversely, EUS-GBD is preferred with indwelling metal biliary stents covering the cystic duct and/or high-volume cholelithiasis. LAMS can be left long term; however, in patients willing to undergo an additional procedure, exchanging the LAMS for plastic stents can be undertaken at 4-6 weeks. Ultimately, more randomized and prospective data are needed to compare ET- and EUS-GBD outcomes, including a formal cost analysis.

Dr. Irani is with Virginia Mason Medical Center, Seattle. He reports being a consultant for Boston Scientific and Gore, as well as remittance to his clinic. These remarks were made during one of the AGA Postgraduate Course sessions held at DDW 2022.

Percutaneous transhepatic gallbladder drainage (PT-GBD) is the most common, nonoperative method for gallbladder decompression in patients unfit for cholecystectomy. However, drain-related complications (20%-75%), including tube changes, dyscosmesis, discomfort, and recurrent cholecystitis (up to 15%), limit its long-term use. Endoscopic transpapillary gallbladder drainage (ET-GBD) and now, endoscopic ultrasound–guided gallbladder drainage (EUS-GBD), have emerged as options.

ET-GBD is performed at endoscopic retrograde cholangiopancreatography (ERCP) by cannulating the cystic duct, allowing placement of a pigtail plastic stent into the gallbladder. However, obstructing pathology (stone, stricture, metal stent or mass) may result in lower technical and clinical success when compared with EUS-GBD (84% vs. 98% and 91% vs. 97%, respectively). Furthermore, it does not allow for treatment of gallstones, and may require stent exchanges.

EUS-GBD involves placing a stent from the duodenum/stomach into the gallbladder under EUS guidance. Initial use of pigtail plastic stents and biliary self-expandable metal stents were not ideal, because of their risk of leakage, longer length (contralateral wall injury, occlusions), and migration (lack of flanges). Lumen-apposing metal stents (LAMS) overcame these limitations because of their short length and large flanges, and their large diameters (up to 20 mm) aid passage of gallstones or cholecystoscopy. Several case series and comparative trials have been published on EUS-GBD including a randomized prospective trial of EUS-GBD vs. PT-GBD demonstrating its superiority. Adverse events are uncommon and include misdeployments, bleeding, perforation, bile leaks, occlusion (commonly with food, prompting some endoscopists to place pigtails stents through the LAMS and avoiding the stomach as a target), and migration.

EUS-GBD should be avoided in patients who have a perforated gallbladder, have large volume ascites, or are too sick to tolerate anesthesia. Although there are patients who have subsequently undergone cholecystectomy post EUS-GBD, a discussion with one’s surgeon must be had prior to choosing this approach over ET-GBD.

In conclusion, determining the ideal method for endoscopic GBD in high-surgical-risk patients requires consideration of comorbidities, anatomy (GB position, cystic duct characteristics), presence of ascites, future surgical candidacy, and local expertise. ET-GBD should be prioritized for patients requiring ERCP for alternative reasons, large volume ascites, and as a bridge to cholecystectomy. Conversely, EUS-GBD is preferred with indwelling metal biliary stents covering the cystic duct and/or high-volume cholelithiasis. LAMS can be left long term; however, in patients willing to undergo an additional procedure, exchanging the LAMS for plastic stents can be undertaken at 4-6 weeks. Ultimately, more randomized and prospective data are needed to compare ET- and EUS-GBD outcomes, including a formal cost analysis.

Dr. Irani is with Virginia Mason Medical Center, Seattle. He reports being a consultant for Boston Scientific and Gore, as well as remittance to his clinic. These remarks were made during one of the AGA Postgraduate Course sessions held at DDW 2022.

Percutaneous transhepatic gallbladder drainage (PT-GBD) is the most common, nonoperative method for gallbladder decompression in patients unfit for cholecystectomy. However, drain-related complications (20%-75%), including tube changes, dyscosmesis, discomfort, and recurrent cholecystitis (up to 15%), limit its long-term use. Endoscopic transpapillary gallbladder drainage (ET-GBD) and now, endoscopic ultrasound–guided gallbladder drainage (EUS-GBD), have emerged as options.

ET-GBD is performed at endoscopic retrograde cholangiopancreatography (ERCP) by cannulating the cystic duct, allowing placement of a pigtail plastic stent into the gallbladder. However, obstructing pathology (stone, stricture, metal stent or mass) may result in lower technical and clinical success when compared with EUS-GBD (84% vs. 98% and 91% vs. 97%, respectively). Furthermore, it does not allow for treatment of gallstones, and may require stent exchanges.

EUS-GBD involves placing a stent from the duodenum/stomach into the gallbladder under EUS guidance. Initial use of pigtail plastic stents and biliary self-expandable metal stents were not ideal, because of their risk of leakage, longer length (contralateral wall injury, occlusions), and migration (lack of flanges). Lumen-apposing metal stents (LAMS) overcame these limitations because of their short length and large flanges, and their large diameters (up to 20 mm) aid passage of gallstones or cholecystoscopy. Several case series and comparative trials have been published on EUS-GBD including a randomized prospective trial of EUS-GBD vs. PT-GBD demonstrating its superiority. Adverse events are uncommon and include misdeployments, bleeding, perforation, bile leaks, occlusion (commonly with food, prompting some endoscopists to place pigtails stents through the LAMS and avoiding the stomach as a target), and migration.

EUS-GBD should be avoided in patients who have a perforated gallbladder, have large volume ascites, or are too sick to tolerate anesthesia. Although there are patients who have subsequently undergone cholecystectomy post EUS-GBD, a discussion with one’s surgeon must be had prior to choosing this approach over ET-GBD.

In conclusion, determining the ideal method for endoscopic GBD in high-surgical-risk patients requires consideration of comorbidities, anatomy (GB position, cystic duct characteristics), presence of ascites, future surgical candidacy, and local expertise. ET-GBD should be prioritized for patients requiring ERCP for alternative reasons, large volume ascites, and as a bridge to cholecystectomy. Conversely, EUS-GBD is preferred with indwelling metal biliary stents covering the cystic duct and/or high-volume cholelithiasis. LAMS can be left long term; however, in patients willing to undergo an additional procedure, exchanging the LAMS for plastic stents can be undertaken at 4-6 weeks. Ultimately, more randomized and prospective data are needed to compare ET- and EUS-GBD outcomes, including a formal cost analysis.

Dr. Irani is with Virginia Mason Medical Center, Seattle. He reports being a consultant for Boston Scientific and Gore, as well as remittance to his clinic. These remarks were made during one of the AGA Postgraduate Course sessions held at DDW 2022.