Keywords
gall bladder - endosonography - endoscopic retrograde cholangiography - ultrasound
Introduction
Acute cholecystitis (AC) is a potentially life-threatening inflammatory condition
of the gall bladder (GB) which can be calculous or acalculous in nature.[1] Nearly 10% of the Indian population is estimated to have gallstones, and 1 to 3%
of these patients develop symptomatic gallstones.[2] Mortality due to acute cholecystitis is approximately 1 to 10% and therefore the
importance of treating it urgently and appropriately.[3] The treatment of choice in AC is early laparoscopic cholecystectomy. However, many
patients are unfit for surgical cholecystectomy either due to high risk of anesthesia/surgery
or unwillingness of patient for surgical cholecystectomy. In such a scenario, it is
important to drain infected GB by other modalities. Various nonsurgical therapeutic
modalities like percutaneous transhepatic cholecystostomy (PTC), endoscopic ultrasound
(EUS)-guided GB drainage, or endoscopic transpapillary drainage of GB have been described
as effective modalities for GB drainage.
PTC is a well-established method of GB drainage. It is associated with higher technical
success rate (> 95%) and higher clinical success rate (90%). However, it is also associated
with higher risk of complications like biliary peritonitis, pneumothorax, and bleeding.
Moreover, risk of accidental slippage of catheter and risk of recurrent cholecystitis
is as high as 10 to 15%.[4]
[5] Studies have shown equal technical and clinical success for percutaneous or EUS-guided
biliary drainage in patients with AC who are unfit for surgical cholecystectomy. However,
PTC has higher complication rate, unplanned hospital readmission rate, tube dislodgement
rate, and higher risk of recurrent acute cholecystitis compared with EUS-guided GB
drainage group.[4]
[5]
[6]
[7] Endoscopic transpapillary drainage of GB is also a well-established method of GB
drainage; however, there are no trials comparing EUS-guided GB drainage with transpapillary
drainage. In this news and views, we have discussed two interesting articles which
have compared EUS-guided GB drainage and endoscopic transpapillary drainage. Although
both the articles are single center and retrospective in nature, the conclusion of
these articles will help an endoscopist to make the correct decision with regard to
the modality of GB drainage in a surgically unfit patient.
Higa JT et al have retrospectively analyzed data of 78 surgically unfit patients who
were referred to their center for GB drainage.[8] They have compared technical and clinical success as well as adverse events between
EUS-guided GB drainage (n = 40) and transpapillary GB drainage (n = 38). The definition and classification of AC was framed according to the Tokyo
guidelines.[9] Technical success was defined as the ability to place transmural lumen-apposing
metal stents (LAMS) under EUS guidance or transpapillary GB stent using endoscopic
retrograde cholangiography (ERCP). The clinical success was defined as resolution
of symptoms along with objective improvement in biochemical and radiographic findings
of cholecystitis within 3 days of intervention. The reintervention was defined as
any endoscopic or interventional radiology procedure for drain placement or stent-related
event occurring within 30 days of the drainage procedure.
In EUS-guided intervention group, both cautery-enhanced or noncautery-enhanced 10
or 15 mm LAMS was used. In transpapillary stenting, once guide wire was negotiated
through cystic duct, a 7 Fr × 15 cm double pigtail stent was placed into the GB. Amongst
baseline characteristics, more patients in endoscopic transpapillary stenting group
were having acute calculous cholecystitis than patients undergoing EUS-guided GB drainage
(71.1 vs. 40%; p = 0.012). On the other hand, patients undergoing EUS-guided GB drainage had more
commonly acalculous cholecystitis, either malignant-related obstruction or stent-related
obstruction. In both the groups, 2/3rd of the patients had moderate cholecystitis
and majority of patients had obstruction at level of cystic duct. The cause of cystic
duct obstruction was either stone (45 vs. 76.3% [EUS vs. transpapillary group]) or
stent (25.0 vs. 10.5%) or tumor (30.0 vs. 13.2%). Technical success was higher in
EUS-guided GB drainage group compared with transpapillary group (84.2 vs. 97.5%; adjusted
OR 9.83, 95% CI 0.93–103.86). Clinical success was also higher in EUS-guided GB drainage
group compared with transpapillary group (95.0 vs. 76.3%; adjusted OR 5.90, 95% CI
1.18–29.41). Patients who underwent EUS-guided LAMS placement were more likely have
kept stent for indefinite period than patients who had underwent transpapillary stent
placement (87.2 vs. 37.5%; OR 11.33, CI 3.48–36.91). Patients who underwent transpapillary
stenting more likely underwent surgery than patients who underwent EUS-guided GB drainage
(43.8 vs. 2.6%; OR 0.034, 95% CI 0.004–0.278). Adverse events occurred equally in
both the arms (17.9% in EUS group vs. 9.4% in transpapillary group; adjusted OR 3.04;
95% CI, 0.58–15.78). In EUS-guided LAMS group, three cases of stent migration were
observed: one intraprocedure stent migration retrieved successfully from the retroperitoneum
and redeployed, one distal migration occurred 5 months postprocedure, in which stent
was retrieved using antegrade double balloon enteroscopy, and one proximal migration
occurred 10 months postprocedure resulting in recurrent cholecystitis treated with
stent revision. Recurrent cholecystitis was more common with transpapillary drainage
compared with EUS drainage (18.8 vs. 2.6%; OR 0.094; 95% CI, 0.011–0.81). Three patients
in transpapillary group who had recurrence of AC were treated with EUS-guided drainage.
However, other parameters like mean duration of antibiotic use, median length of postprocedure
hospital stay, and median postprocedure pain score was similar in both the groups.
Three patients in the EUS group had significant ascites for which authors had aspirated
ascites under EUS guidance and continued paracentesis on a weekly basis for 4 weeks
to facilitate cholecysto-duodenal fistula formation. Authors have also concluded that,
ideally, transpapillary stenting should be the first line of treatment modality in
patients with ascites. Only in case of failure of transpapillary drainage, one should
attempt EUS-guided GB drainage.
In pancreatic fluid collections drained by LAMS, recent studies have shown adverse
effects of indwelling LAMS for more than 3 weeks with development of pseudoaneurysm
and risk of “buried stent.” However, ideal time of removal of LAMS used for GB drainage
is not well-defined at present. In this study, authors have shown that 18 patients
had long term follow-up of indwelling LAMS (> 1 year) without any major side effect.
However, at the same time, authors have also suggested that 7F*3cm double pigtail
plastic stent can be used to replace the LAMS in order to reduce chances of injury
to contralateral GB wall. The authors concluded that in patients who are surgical
candidates requiring only temporary measures to drain GB or patients with significant
ascites, transpapillary drainage should be considered as the first-line treatment
option. However, in patients with stent-related cystic duct obstruction or malignant
obstruction or patients who are poor surgical candidates, EUS-guided GB drainage can
be considered as first-line treatment option in view of higher technical and clinical
success and lower risk of recurrent cholecystitis.
Oh et al performed retrospective analysis of 172 patients with AC undergoing EUS-guided
cholecystostomy or endoscopic transpapillary cholecystostomy.[10] Definition and classification of AC was framed according to Tokyo guidelines. All
included patient had failed conservative medical management for at least 24 hours.
EUS-guided drainage was preferred in patients with malignant cystic duct obstruction,
bile duct cancer, and cystic duct obstruction due to metallic stent placement or unsuccessful/infeasible
transpapillary drainage. Endoscopic transpapillary drainage was performed when obstruction
occurred due to cystic duct stone or associated common bile duct (CBD) stone. Technical
success was defined as ability to place transmural metallic stent (BONA-AL stent;
Standard Sci-Tech Inc, Seoul, Korea) under EUS guidance or transpapillary GB stent
(7F stent) using ERCP. Clinical success was defined as resolution of symptoms along
with normalization of laboratory tests. Recurrence of cholecystitis was defined as
the recurrence of typical symptoms with characteristic imaging findings.
In their study, 96 patients underwent endoscopic transpapillary drainage and 76 patients
underwent EUS-guided GB drainage. Seven out of 16 patients who failed transpapillary
drainage cross over to EUS-guided GB drainage, making it 83 patients in EUS-guided
GB drainage group. In the transpapillary group, more patients had CBD stone (29.2
vs. 7.2%; p < 0.01) and less patients had malignancy (67.5 vs. 20.8%; p < 0.01) as an etiology compared with EUS-guided GB drainage. EUS-guided GB drainage
group had more technical (98.8 vs. 83.3%; p < 0.01) and clinical success rate (98.8 vs. 82.3%; p < 0.01) compared with endoscopic transpapillary group by intention to treat analysis.
However, there was no statistical difference in clinical success rate by per-protocol
analysis between both the groups (100 vs. 98.8%; p = 0.49). In the EUS-guided GB drainage group, the procedure failed in one patient
(1.2%) because of accidental loss of the guide wire during stent placement. In the
endoscopic transpapillary group, the procedure failed in 16 patients (16.7%) because
of selective cystic duct cannulation failure (n = 12) or nonvisualization of the cystic duct because of cystic duct obstruction (n = 4). Procedure time (18.3± 4.9 vs. 19.5 ± 9.6 minute; p = 0.31) and procedure-related adverse events (7.2 vs. 9.4%; p = 0.75) were similar in both the groups. In the EUS-guided GB drainage group, pneumoperitoneum
occurred in three patients (3.6%), duodenal perforation in one patient (1.2%), and
recurrent biliary pain in two patients (2.4%). In patients with recurrent biliary
pain, additional double pigtail plastic stents were placed to maintain the stent patency.
In the endoscopic transpapillary group, eight patients experienced post-ERCP pancreatitis
which improved after conservative treatment. Recurrent biliary pain occurred in one
patient after 3 days of procedure. In this study, only five patients underwent elective
laparoscopic cholecystectomy. Recurrent cholecystitis was more common in endoscopic
transpapillary group versus EUS-guided GB drainage group (17.4 vs. 3.9%; p = 0.05). In EUS-guided GB drainage group, three patients experienced recurrent cholecystitis
because of stent strut fracture (n = 2) or stent occlusion because of food impaction (n = 1), while in the endoscopic transpapillary group, 10 patients experienced recurrent
cholecystitis because of distal stent migration (n = 6) or stent occlusion (n = 4). The authors concluded that although both modalities of GB drainage are safe
and effective, EUS-guided GB drainage may be more suitable due to better clinical
success and lesser risk of recurrent AC.[10]
Commentary
Acute cholecystitis, either calculus or non-calculus, is associated with higher morbidity
and mortality. Treatment of choice in such a scenario is usually surgical cholecystectomy.
However, in up to 10% of patients, surgical removal of GB is not feasible due to various
reasons. In such a scenario, if patient is fit for endoscopy, endoscopic GB drainage
is preferred over percutaneous transhepatic drainage due to lower risk of complications
and lesser risk of recurrent AC. In endoscopic modalities, there are two different
modalities: EUS-guided GB drainage and endoscopic transpapillary drainage. These studies,
although retrospective, showed that EUS-guided biliary drainage has better technical
and clinical success with lesser risk of recurrent cholecystitis. These studies have
not conducted subgroup analysis of clinical success and risk of recurrent cholecystitis
according to the etiology of AC. Although several studies have used LAMS for EUS-guided
GB drainage, there are still certain unanswered questions like ideal time for removal
of LAMS or exchanging it with plastic stent. Also, unique difficulties that surgeon
might face due to LAMS during elective cholecystectomy are still not defined. Siddiqui
et al compared PTC (n = 146), EUS-guided GB drainage (n = 124), and endoscopic transpapillary drainage (n = 102) retrospectively. They also found that endoscopic transpapillary drainage had
lesser technical and clinical success rates compared with other two modalities. EUS-guided
GB drainage group had shorter hospital stay and less long-term adverse events rate
compared with PTC and transpapillary group.[11]
To conclude, both modalities of endoscopic GB drainage are associated with high technical
and clinical success rates. Endoscopic transpapillary drainage should be preferred
in patients with benign obstruction or in presence of CBD stone. It should be ideally
used as a temporary bridge therapy in patients who are good surgical candidates. However,
due to high risk of recurrent AC, its use as a definitive long-term modality to drain
GB should be avoided. EUS-guided GB drainage should preferentially be used in presence
of malignant cystic duct obstruction or cystic duct obstruction due to metallic stent.
Due to lower risk of recurrent AC, it can be used as a definitive measure to drain
GB in a poor surgical candidate patient.
