10.1055/a-0747-5668According to Tokyo Guidelines 2018, the basic treatment for acute cholecystitis (AC)
is cholecystectomy [1]
[2]
[3]
[4]. However, there are several risks associated with emergency surgery, and depending
on the capabilities of surgeons and anesthesiologists in some hospitals, it is not
always possible to perform an emergency or early operation. In such a case, gallbladder
drainage is selected as a palliative treatment. Cholecystectomy is finally recommended
for cases of cholecystectomy drainage or conservative treatment.
For general initial treatment of AC, fasting, infusion, and antibiotics are administered,
and analgesics are administered if the pain is strong. Tokyo Guidelines 2018 (TG18)
gives a severity treatment strategy for AC [1]
[2]. In mild (Grade I) AC, TG18 recommends early laparoscopic cholecystectomy (Lap-C)
if the patients meet the criteria of Charlson comorbidity index (CCI) ≤ 5 and the
American Society of Anesthesiologists physical status classification (ASA-PS) ≤ 2.
Grade II (moderate) AC is often accompanied by severe local inflammation. Therefore,
surgeons should take the difficulty of cholecystectomy into consideration in selecting
a treatment method. If patients meet the criteria of CCI ≤ 5 and ASA-PS ≤ 2, TG18
recommends early Lap-C performed by experienced surgeons; and if not, after medical
treatment and/or gallbladder drainage, Lap-C would be indicated. In severe (Grade
III) AC, systemic management for accompanying organ failure is needed. These are that
the patients have favorable organ system failure (FOSF) and negative predictive factors,
who meet the criteria of CCI ≤ 3 and ASA-PS ≤ 2, and who are being treated at an advanced
center (where experienced surgeons practice). If the patient is not considered suitable
for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed
Lap-C once the patient’s overall condition has improved.
The indication for gallbladder drainage, as mentioned above, follows the strict criteria
of TG18; briefly, when the patient’s general condition is poor and unable to bear
anesthesia, when the condition does not respond to mild and conservative treatment,
and when an emergency operation cannot be performed due to the problem of the capability
of the surgeon/anesthesiologist, then gallbladder drainage is selected. Gallbladder
drainage improves pain and promptly improves inflammation. Methods of gallbladder
drainage include percutaneous drainage and endoscopic drainage. Percutaneous drainage
includes percutaneous transhepatic gallbladder aspiration (PTGBA) and percutaneous
transhepatic drainage (PTGBD). Endoscopic drainage includes endoscopic transpapillary
gallbladder drainage and EUS-guided gallbladder drainage (EUS-GBD). TG18 recommends
PTGBD as a standard drainage method for surgically high risk patients with AC [3]. As a result of an international multicenter comparative study on the treatment
of AC, Itoi et al. [5] reported that PTGBD showed similar clinical efficacy compared with endoscopic gallbladder
drainage including EUS-GBD and endoscopic transpapillary gallbladder drainage without
a significant increase in complication rate.
Endoscopic transpapillary gallbladder drainage can be divided into two different methods:
endoscopic naso-gallbladder drainage (ENGBD) and endoscopic gallbladder stenting (EGBS).
These transpapillary procedures are used to place a drainage tube in the gallbladder
via the cystic duct in the same manner as with endoscopic retrograde cholangiopancreatography
(ERCP) [6]. Before this, endoscopic transpapillary gallbladder drainage was used for gallbladder
cytology, etc. Recently, it has become a procedure that is being used as one of the
treatment options for AC. The difficulty is that the success rate is not necessarily
high as the approach requires specialist knowledge and experience. However, it is
an effective procedure in patients with ascites, severe coagulopathy, thrombocytopenia,
or an anatomically inaccessible location [7]. In addition to the procedural difficulty, another problem with this approach is
the risk of cystic duct perforation. The cystic duct may also cause edematous changes
in situations where inflammation of the gallbladder is spreading to the cystic duct.
In such a situation, the cystic duct wall is very weak and there is a tendency for
perforation by the guidewire to occur easily. According to TG18, endoscopic transpapillary
gallbladder drainage is supposed to be performed at facilities with skilled endoscopists
in high volume centers [3]. Considering situations where preventive anticoagulants and antiplatelet agents
are administered, endoscopic transpapillary gallbladder drainage occupies an important
position when gallbladder drainage is required during AC. Moreover, it is expected
that its success rate will increase as a result of improvements in endoscopic treatment
devices.
Redesigned plastic stents are expected to be developed for AC. The novel stent in
the paper by Nakahara et al. [8] has a unique structure and shape. The tip of the stent has a three-dimensional spiral-shaped
structure, and there are sideholes inside the spiral, compared to conventional double-pigtail
type stents. This is expected to prevent migration of the stent and, even if the stent
adheres to the constricted gallbladder wall, drainage will be maintained without the
sideholes being blocked. The shaft of the stent is semicircular and fits the anatomical
shape of the cystic duct, and the sidehole of the shaft is designed to drain the bile
from the common bile duct. The distal side of the stent is straight, with a flap to
prevent proximal migration. The novel stent is reported to have significantly lower
rates of late adverse events and stent migration compared to earlier stents. Although
this paper was a retrospective study, this novel stent may be effective for AC and
a randomized controlled trial is expected shortly.
Regarding the choice of ENGBD or EGBS, according to a randomized controlled trial
by Itoi et al. with ENGBD and EGBS groups [9], the procedure success rate was 92 % in the ENGBD group and 86 % in the EGBS group,
and the clinical response rates were 87 % and 78 %, respectively with no significant
differences between the two groups. There was also no significant difference between
the two groups for procedure time or adverse events. Therefore, ENGBD and EGBS are
useful and confirmed to be safe, and either ENGBD or EGBS may be considered for gallbladder
drainage based on the patient’s background and the endoscopist’s decision [3].
The procedure for endoscopic gallbladder drainage [6] is as follows: 1. Deep bile duct cannulation from the papilla under ERCP. 2. Visualize
the cystic duct by cholangiography. There are possible variations due to the combination
of the diameter of the common bile duct, the number and size of gallstones compressing
the cystic duct, the orientation of the cystic duct, etc. Considering these variations,
several tries may be necessary to find the cystic duct with a guidewire. 3. Find a
helical cystic duct with a hydrophilic guidewire and carefully advance the guidewire.
4. Advance the guidewire to the deep portion of the gallbladder. 5. Allow the catheter
to follow the gallbladder along the guidewire. 6. Replace the hydrophilic guidewire
with a stiff type guidewire. 7. Insert a 5 Fr or 6 Fr tip pigtail-type transnasal
biliary drainage tube or 7 Fr pigtail-type bile duct plastic stent in the gallbladder.
8. Endoscopic sphincterotomy (EST) may be added because of concerns over possible
obstructive pancreatitis when inserting a stent with a diameter larger than 7 Fr.
Keeping in mind that possible pancreatitis may occur with a transpapillary approach,
the procedure should be completed promptly without sticking in difficult cases, although
this is often difficult; however, a transhepatic approach may also be considered.
Under such circumstances, the EUS-GBD technique has attracted attention in recent
years [10]; however, it has not yet been standardized. In future, with device development and
establishment of endoscopic procedures, EUS-GBD may become the preferred treatment
for AC for endoscopists accustomed to EUS intervention.