Three-way comparative study of endoscopic ultrasound-guided transmural gallbladder drainage using lumen-apposing metal stents versus endoscopic transpapillary drainage versus percutaneous cholecystostomy for gallbladder drainage in high-risk surgical patients with acute cholecystitis: clinical outcomes and success in an International, Multicenter Study

Endoscopic management of acute cholecystitis in high-risk surgical patients: A comprehensive review article

Acute cholecystitis is frequently encountered in daily clinical practice, and early cholecystectomy is the standard therapy. In high-risk surgical patients, such as those with advanced age, deteriorated performance status, or underlying diseases, conservative treatment is typically preferred to manage acute cholecystitis. However, in patients with a disease that is refractory to conservative treatment, drainage procedures are necessary to control the infection. At present, there are three basic approaches for gallbladder drainage: percutaneous transhepatic gallbladder drainage, endoscopic transpapillary gallbladder drainage, and endoscopic ultrasound gallbladder drainage. Each of these methods has advantages and disadvantages. Therefore, the appropriate treatment method is determined on a case-by-case basis, and no consistent strategy for gallbladder drainage has been established. This review aimed to summarize the characteristics of each drainage method and compare the clinical outcomes of the three procedures for acute cholecystitis in high-risk surgical patients.

Endoscopic Gallbladder Drainage EUS LAMS vs. ERCP Trans-papillary Drainage

PURPOSE OF REVIEW

In this review, we discuss the role of endoscopic gallbladder drainage for acute cholecystitis in non-surgical candidates, describe technical aspects, clinical outcomes, and elaborate on considerations when determining which approach to adopt for a given patient.

RECENT FINDINGS

Cholecystectomy remains the criterion standard for management of acute cholecystitis in patients who can safely undergo surgery. For non-surgical candidates, percutaneous cholecystostomy (PTC-GBD) has been the traditional strategy to drain and decompress the gallbladder. Advances in endoscopy have further expanded the nonsurgical interventions and approaches to cholecystitis. Both endoscopic transpapillary gallbladder drainage (ET-GBD) and endoscopic ultrasound guided gallbladder drainage (EUS-GBD) have become acceptable alternatives to PTC-GBD, with growing literature supporting their efficacy, safety and improved patient quality of life when compared to a percutaneous approach. Choosing the appropriate endoscopic technique for gallbladder drainage should be tailored to each patient, keeping in view the specific clinical scenarios, endoscopist preference and following a multi-disciplinary approach.

Safety and effectiveness of endoscopic ultrasound-guided gallbladder drainage in patients with cirrhosis: an international multicenter experience

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) for symptomatic gallbladder disease has been shown to be safe and effective in patients with high surgical risk, but data are lacking for patients with cirrhosis. We investigated the safety and effectiveness of EUS-GBD in patients with and without cirrhosis.This retrospective review included patients who underwent EUS-GBD at four (three US and one Spanish) international tertiary care centers. Outcomes, including technical success, clinical success, and procedure-related adverse events, were compared between patients with and without cirrhosis.170 patients (47 with cirrhosis, 123 without cirrhosis) were included. There was no difference in age, sex, race, comorbidities, antiplatelet use, hemoglobin, or international normalized ratio between the two groups (P > 0.05 for all). The most common etiology of cirrhosis was alcohol (42.6%) with mean Model of End-stage Liver Disease-Sodium (MELD-Na) score of 16.2 (SD 8.8). Acute cholecystitis was more common in patients with cirrhosis (74.5% vs. 56.9%; P = 0.02). Technical (cirrhosis 97.9% vs. no cirrhosis 95.1%; P = 0.67) and clinical (93.6% vs. 94.9%; P = 0.71) success rates were similar in the two groups. Adverse events were infrequent and similar between groups, the most common being stent maldeployment (cirrhosis 4.3% vs. no cirrhosis 5.7%; P = 0.99). Survival rates were similar at the end of follow-up.EUS-GBD was safe and effective in patients with cirrhosis, with outcomes similar to patients without cirrhosis when performed by experienced echoendoscopists. Patients with cirrhosis and symptomatic gallbladder disease can be considered for EUS-GBD.

Feasibility of endoscopic transpapillary gallbladder drainage for acute gangrenous cholecystitis in poor surgical candidates

OBJECTIVES

Surgery is generally the first choice of treatment for gangrenous cholecystitis (GC). However, some patients are not fit for surgery because of their comorbidities. We evaluated the feasibility of endoscopic transpapillary gallbladder drainage (ETGBD) for GC in poor surgical candidates.

METHODS

This retrospective study compared the outcomes of ETGBD for acute cholecystitis (AC) with and without complicated GC. Of the 136 patients who underwent ETGBD for AC at a single tertiary referral center between January 2019 and July 2023, 91 who underwent contrast-enhanced computed tomography (CT) before ETGBD were included in the analysis.

RESULTS

Patients were assigned to the GC (n = 29) and non-GC (n = 62) groups based on CT findings. The technical success rate of ETGBD, clinical success rate for AC, and rate of early adverse events (AEs) in the GC and non-GC groups were 86.2% vs. 91.9% (P = 0.63), 79.3% vs. 91.9% (P = 0.17), and 27.6% vs. 16.1% (P = 0.32), respectively. The technical and clinical success rates were slightly lower, while the early AE rate was higher in the GC group. However, the differences were not significant. The incidence of late AEs was 15.8% in the GC group and 17.9% in the non-GC group, with no significant difference (P = 0.87). Elective cholecystectomy was significantly less frequent in the GC group (P = 0.023).

CONCLUSION

ETGBD is a feasible treatment option for GC in patients contraindicated for surgery.

Percutaneous endoscopy-guided gallbladder lumen-apposing metal stent retrieval, lithotripsy, and cholecystoduodenal stenting in a patient with acute cholecystitis

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with lumen apposing metal stent (LAMS) has emerged as an effective alternative to percutaneous cholecystostomy in managing acute cholecystitis patients with contraindications to open or laparoscopic cholecystectomy. Herein, the authors describe a case of a 69-year-old male who presented to interventional radiology with sepsis due to acute calculous cholecystitis and LAMS migration into the gallbladder. After stabilizing the patient with percutaneous cholecystostomy, percutaneous cholecysto-lithotripsy/lithectomy, cholecystoduodenal stenting, and LAMS retrieval were performed. This report highlights the potential complications associated with EUS-GBD with LAMS insertion and contributes to the limited literature on percutaneous management of migrated LAMS.

Outcomes of interval cholecystectomy after EUS-guided gallbladder drainage: a systematic review and meta-analysis

BACKGROUND AND AIMS

Cholecystectomy (CCY) is considered the criterion standard intervention for acute cholecystitis (AC). However, EUS-guided gallbladder drainage (EUS-GBD) can be performed in patients unfit for surgery. Interval CCY after EUS-GBD is typically not performed because the formation of a cholecystoenteric fistula increases the technical complexity of CCY. We conducted a systematic review and meta-analysis to determine the outcomes of interval CCY after EUS-GBD.

METHODS

We conducted a literature search of multiple electronic databases for studies reporting on outcomes of interval CCY after EUS-GBD. Primary outcomes were pooled proportions of technical success of interval CCY and surgical techniques (rate of open, laparoscopic, and conversion from laparoscopic to open). The secondary outcome was adverse events (AEs). A meta-analysis of proportions was performed using the random-effects model. The I2 statistic was used to assess heterogeneity.

RESULTS

Of 1001 citations, 15 studies with 707 patients were included. The pooled proportion of successful interval CCY was 32.9% (95% CI, 11.8-53.9%; I2 = 99%). Surgical techniques included laparoscopic CCY in 76.2% (95% CI, 61.5-91.0%; I2 = 82%), open CCY in 14.5% (95% CI, 4.2-24.8%; I2 = 82%), and conversion from laparoscopic to open CCY in 14% (95% CI, 4.1-23.8%; I2 = 77%). The pooled proportion of overall AEs was 13.2% (95% CI, 4.3-22.1%; I2 = 61%), including postoperative infection in 7.6% (95% CI, 0.7-14.6%; I2 = 65%). There was no procedure-related mortality.

CONCLUSIONS

Our study demonstrates that interval CCY is technically feasible and safe after EUS-GBD. Endoscopists should still consider the local surgical expertise and recommendations before performing EUS-GBD in patients who could eventually become surgical candidates afterward.

Endoscopic transpapillary gallbladder stenting vs percutaneous cholecystostomy for managing acute cholecystitis: Nationwide propensity score study

Background and study aims

Cholecystectomy is the standard treatment for acute cholecystitis, but it may not be suitable for all patients. For those who cannot undergo surgery, a percutaneous cholecystostomy tube (PCT) and ERCP-guided transpapillary gallbladder drainage are viable options. We aimed to perform a nationwide study to assess 30-day readmission rates, adverse events (AEs), and mortality rates in these two cohorts.

Patients and methods

We conducted a nationwide cohort study using data from the Nationwide Readmissions Database (NRD) from 2016 to 2019. We identified patients with acute cholecystitis during the index admission who underwent either PCT or ERCP-guided gallbladder drainage. Propensity score matching along with multivariable regression was used to compare cohorts.

Results

During the study period, 3,592 patients (average age 63.0 years) underwent endoscopic drainage, whereas 80,372 patients (average 70.8 years) underwent Interventional Radiology drainage. Utilizing multivariate Cox regression analysis, compared with ERCP, PCT had a higher risk for 30-day readmission (adjusted hazard ratio [aHR] 1.47; 95% confidence interval [CI] 1.27 to 1.71; P < 0.001). The PCT group had a significantly higher rate of readmission for acute cholecystitis compared with the ERCP group (2.72% vs 0.86%; P < 0.005). Cox proportional hazard ratio showed a 3.41-fold increased risk (95% CI 1.99 to 5.84) for readmission in the PCT group. ERCP was consistently associated with lower rates of post-procedural AEs compared with PCT including acute hypoxemic respiratory failure ( P < 0.001), acute renal failure ( P < 0.001), shock ( P < 0.001), and need for blood transfusions ( P < 0.001).

Conclusions

Our nationwide analysis revealed that ERCP-guided gallbladder drainage should be the preferred approach for managing acute cholecystitis when unfit for surgery.

EUS-guided gallbladder drainage vs dual stent transpapillary gallbladder drainage for management of acute cholecystitis

Background and study aims

Cholecystectomy (CCY) is the standard treatment for acute cholecystitis. For non-surgical patients, percutaneous cholecystostomy tube (PT-GBD) is recommended but is associated with high readmission rates and poor quality of life. Endoscopic gallbladder decompression techniques, including endoscopic transpapillary gallbladder drainage (ET-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), are alternatives. Studies comparing ET-GBD and EUS-GBD have shown EUS-GBD to have superior outcomes. However, these studies assessed ET-GBD mostly via single transcystic stent placement (SSET-GBD). This study aimed to compare outcomes of dual transcystic stents (DSET-GBD) and EUS-GBD in non-surgical candidates with acute cholecystitis.

Patients and methods

A multicenter analysis was conducted on patients who underwent ET-GBD or EUS-GBD between January 2019 and January 2023. Data were extracted from electronic medical records and outcomes including technical success, success, adverse events (AEs), and recurrence rates of cholecystitis were measured.

Results

Of 129 procedures (56 EUS-GBD; 73 ET-GBD), technical success was achieved in 87.5% of EUS-GBD and 86.3% of ET-GBD attempts. Immediate clinical success was achieved in 98.1% for EUS-GBD and 100% for DSET-GBD. AE rates were similar between the groups. Recurrent cholecystitis rates were 5.3% for EUS-GBD and 8.2% for DSET-GBD ( P = 0.692).

Conclusions

This study demonstrates that DSET-GBD has similarly low rates of recurrent acute cholecystitis compared with EUS-GBD. DSET-GBD should be considered as an alternative management strategy for management of acute cholecystitis in patients who are unable to undergo CCY.

Endoscopic Management of Benign Pancreaticobiliary Disorders

Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications.

US multicenter outcomes of endoscopic ultrasound-guided gallbladder drainage with lumen-apposing metal stents for acute cholecystitis

Background and study aims

EUS-guided gallbladder drainage (EUS-GBD) using lumen apposing metal stents (LAMS) has excellent technical and short-term clinical success for acute cholecystitis (AC). The goals of this study were to determine the long-term clinical outcomes and adverse events (AEs) of EUS-GBD with LAMS.

Patients and methods

A multicenter, retrospective study was conducted at 18 US tertiary care institutions. Inclusion criteria: any AC patient with attempted EUS-GBD with LAMS and minimum 30-day post-procedure follow-up. Long-term clinical success was defined as absence of recurrent acute cholecystitis (RAC) > 30 days and long-term AE was defined as occurring > 30 days from the index procedure.

Results

A total of 109 patients were included. Technical success was achieved in 108 of 109 (99.1%) and initial clinical success in 106 of 109 (97.2%). Long-term clinical success was achieved in 98 of 109 (89.9%) over a median follow-up of 140 days (range 30-1188). On multivariable analysis (MVA), acalculous cholecystitis (odds ratio [OR] 15.93, 95% confidence interval [CI] 1.22-208.52, P = 0.04) and the occurrence of a LAMS-specific AE (OR 63.60, 95% CI 5.08-799.29, P <0.01) were associated with RAC. AEs occurred in 38 of 109 patients (34.9%) at any time, and in 10 of 109 (9.17%) > 30 days from the index procedure. Most long-term AEs (7 of 109; 6.42%) were LAMS-specific. No technical or clinical factors were associated with occurrence of AEs. LAMS were removed in 24 of 109 patients (22%). There was no difference in RAC or AEs whether LAMS was removed or not.

Conclusions

EUS-GBD with LAMS has a high rate of long-term clinical success and modest AE rates in patients with AC and is a reasonable destination therapy for high-risk surgical candidates.

Feasibility of a novel 5F plastic stent in endoscopic transpapillary gallbladder drainage for acute cholecystitis

Background and study aims

Many reports have demonstrated the efficacy of endoscopic transpapillary gallbladder stenting (EGBS) for acute cholecystitis (AC), most of which have traditionally used a 7F plastic stent. The study aim was to evaluate the efficacy of a novel 5F plastic stent in EGBS for AC.

Patients and methods

We designed a retrospective study that compared the outcomes between 7F and 5F stents in patients undergoing EGBS. Among 147 patients who underwent endoscopic transpapillary gallbladder drainage for AC between January 2019 and July 2023, 104 who underwent EGBS using a 7F (n = 53) or 5F (n = 51) plastic stent were included in the analysis.

Results

The technical success rate for EGBS, clinical success rate for AC, and early adverse events (AEs) rate in the 7F and 5F groups were 92.5% vs 100%, 100% vs 98.0%, and 5.7% vs 3.9%, respectively, with no significant differences. However, only in the 7F group, four patients failed stent insertion and three patients developed postprocedure pancreatitis. Furthermore, incidence of hyperamylasemia was lower in the 5F group (24.5% vs 9.8%, P = 0.047). The late AE rate did not differ significantly between the 7F and 5F groups (14.3% vs 10.0%). The median time to late AE was 238 days for the 7F group and 187 days for the 5F group, with no significant difference.

Conclusions

A 5F stent can provide outcomes comparable to those of a 7F stent and help prevent hyperamylasemia.

Endoscopic transpapillary gallbladder drainage is associated with favorable long-term outcomes in patients with advanced liver disease

Background and study aims Endoscopic gallbladder therapy is increasingly used in high-risk surgical patients, but data in advanced liver disease are lacking. Patients and methods We performed a single-center retrospective analysis of patients with cirrhosis undergoing endoscopic transpapillary gallbladder drainage (ET-GBD) with cystic duct stenting (n = 55). Short-term outcomes were assessed at Day 30. Long-term outcomes were assessed at 6 months and 1 and 3 years or last known follow-up. Subgroup analyses were completed by location (inpatient vs. outpatient). Results A total of 52 patients, mean MELD-Na 16, underwent successful ET-GBD (38 inpatient, 14 outpatient). Most patients (n = 48) experienced immediate symptomatic relief. Short-term adverse event rate was 7.7% and 30-day mortality was 1.9%. At 6 months, 86.5% of patients had a favorable outcome; unfavorable outcomes included death (n = 2), recurrent cholecystitis and/or need for urgent cholecystectomy (n = 5). At the end of the study, 80% of patients experienced a favorable outcome including five patients bridged to liver transplant and 20 who had their stent in place with adequate symptom control. Of those with imaging, 65% of patients experienced resolution of cholelithiasis. Recurrent cholecystitis ( P = 1.00) and stone resolution ( P = 0.35) did not differ in patients with one or two cystic duct stents in place. Conclusions Transpapillary gallbladder stenting is technically feasible and associated with high rates of clinical success in patients with decompensated liver disease. Stone resolution is common after transpapillary gallbladder stenting and may portend favorable patient outcomes.

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis

With technological advances in endoscopic ultrasonography, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was introduced as a treatment option for acute cholecystitis. Recently, new studies have emerged, suggesting that EUS-GBD has a lower adverse event rate and reintervention rate, when compared to percutaneous drainage and endoscopic transpapillary gallbladder drainage. There is growing interest in the different technical aspects of EUS-GBD, such as the puncture approach, choice of stents, and long-term management. There are also cohorts on performing EUS-GBD in potential surgical candidates. This review article gathers the latest evidence on EUS-GBD, including its indications, procedural techniques, choice of equipment, outcomes, postprocedural care, and the controversial extended indications.

Management and outcomes of antithrombotic therapy in EUS-guided gallbladder drainage

BACKGROUND AND AIMS

EUS-guided gallbladder drainage (EUS-GBD) is increasingly used for the management of gallbladder disease in patients at high risk for cholecystectomy. These patients often have underlying medical comorbidities requiring anticoagulation and/or antiplatelet therapy. We evaluated the safety, management, and outcomes of EUS-GBD in patients being treated with antithrombotic therapy (ATT).

METHODS

We performed a retrospective study of patients undergoing EUS-GBD between 2018 and 2023 within Geisinger Health System. Outcomes were analyzed between patients previously on ATT but held for the procedure compared with no ATT. Primary outcomes were bleeding within 48 hours and 30 days. Secondary outcomes were risk of thrombotic events, length of stay, and 30-day mortality.

RESULTS

Of 177 patients undergoing EUS-GBD, 118 patients were on ATT. No statistical difference was found for EUS-GBD-related bleeding for patients on ATT compared with no ATT within 48 hours (.9% vs 0%, P > .999) or within 30 days (3.5% vs 0%, P = .302). Overall, 5 patients (2.9%) had bleeding related to the EUS-GBD procedure. There was no difference between the groups for secondary outcomes: thrombotic events (2.5% vs 3.4%), length of stay (7 days vs 5 days), and 30-day mortality (11% vs 10.2%).

CONCLUSIONS

Patients undergoing EUS-GBD who require ATT did not have any immediate or delayed increased risk of bleeding, thrombotic events, length of stay, or mortality when the medication was appropriately held.

Therapeutic Endoscopic Ultrasound and Endoscopic Ultrasound-Endoscopic Retrograde Cholangiopancreatography Interventions

Therapeutic endoscopic ultrasound (EUS) encompasses an array of procedures to manage pancreaticobiliary and luminal gastrointestinal disorders. Therapeutic EUS procedures include EUS-guided rendezvous of the pancreatic and biliary ducts, as well as direct drainage of the bile duct, pancreatic duct, and gallbladder, drainage of pancreatic fluid collections, and luminal anastomosis creation. These procedures have a range of required equipment, approaches, clinical outcomes, and adverse events dependent on both procedure-related and patient-related factors. In expert hands, these procedures provide patients with less invasive options and can achieve excellent clinical outcomes.

Clinical update on acute cholecystitis and biliary pancreatitis: between certainties and grey areas

Acute calculous cholecystitis (ACC) and acute biliary pancreatitis (ABP) are significant complications of gallstone disease. This review aims to provide a comprehensive analysis of current management practices for ACC and ABP. The Tokyo Guidelines (TG) and World Society of Emergency Surgery (WSES) guidelines recommend early laparoscopic cholecystectomy (ELC) as the treatment of choice for ACC. High-risk patients may benefit from alternative treatments like biliary drainage, with emerging techniques such as endoscopic drainage showing promise. ABP requires prompt diagnosis and intervention. The Revised Atlanta Classification (RAC) criteria are used for diagnosis, with endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy as primary treatments. Minimally invasive approaches are preferred for managing complications like infected pancreatic necrosis, with the endoscopic step-up method showing superior outcomes. The management of ACC and ABP continues to evolve. Future research is needed to refine guidelines further and address existing controversies, ultimately improving patient outcomes in these acute biliary conditions.

Approaches to Cholecystitis: Surgical, Endoscopic, and Percutaneous Management

Acute cholecystitis (AC) is associated with significant morbidity and mortality. Minimally invasive laparoscopic cholecystectomy remains the gold standard of treatment. Therapeutic endoscopy for management of AC continues to emerge as a favorable alternative to percutaneous gallbladder drainage in patients with prohibitive operative risk. Endoscopic management of AC includes transpapillary and transmural stenting. When patient-specific factors prevent both surgical and endoscopic treatment, percutaneous cholecystostomy tube (PCT) placement is an option. Early studies show PCT to have worse outcomes when compared against all other described treatment options for the management of AC.

The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis

BACKGROUND

We investigated the success and complication rates of endoscopic transpapillary gallbladder drainage (ETGBD) and percutaneous transhepatic gallbladder drainage (PTGBD) and the outcomes of subsequent cholecystectomy for acute cholecystitis.

METHODS

Patients (N=178) who underwent cholecystectomy after ETGBD or PTGBD were retrospectively assessed.

RESULTS

ETGBD was successful in 47 (85.5%) of 55 procedures, whereas PTGBD was successful in 123 (100%) of 123 sessions ( P <0.001). Complications related to ETGBD and PTGBD occurred in 6 (12.8%) of 47 and 16 (13.0%) of 123 patients, respectively ( P =0.97). After propensity matching, 43 patients from each group were selected. Median time from drainage to cholecystectomy was 48 (14 to 560) days with ETGBD and 35 (1 to 90) days with PTGBD ( P =0.004). Laparoscopy was selected more often in the ETGBD group (97.7%) than in the PTGBD group (79.1%) ( P =0.007), and conversion from laparoscopy to open cholecystectomy was more common with PTGBD (41.2%) than with ETGBD (7.1%) ( P <0.001). Mean operation time was significantly shorter with ETGBD (135.8±66.7 min) than with PTGBD (195.8±62.2 min) ( P <0.001). The incidence of Clavien-Dindo grade ≥III postoperative complications was 9.3% with ETGBD and 11.6% with PTGBD ( P =0.99).

CONCLUSIONS

The success rate is lower but completion of laparoscopic cholecystectomy is more in endoscopic gallbladder drainage than percutaneous gallbladder drainage for acute cholecystitis.

Single-Session Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography and Simultaneous Endoscopic Ultrasound-Guided Transmural Gallbladder Drainage in Choledocholithiasis and Acute Cholecystitis After Unsuccessful Laparoscopic Cholecystectomy

In patients considered high risk of laparoscopic cholecystectomy, percutaneous gallbladder drainage is traditionally considered first-line treatment option. Recent evidence supports endoscopic gallbladder drainage as a safe and feasible alternate option. We describe a case of Roux-en-Y gastric bypass surgery patient with acute cholecystitis and choledocholithiasis with unsuccessful laparoscopic cholecystectomy because of difficult operative field, underwent successful single-session endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided transmural gallbladder drainage at our institution.

Large Single-center Experience with Long-term Outcomes of EUS-guided Transmural Gallbladder Drainage

GOALS

To describe the long-term outcomes of patients after EUS-guided gallbladder drainage (EUS-GBD), including those who underwent standardized stent exchanges for permanent plastic stents.

BACKGROUND

EUS-GBD has become one of the first-line alternatives for gallbladder decompression, with outcomes and safety profiles comparable to that of percutaneous gallbladder drainage. However, the long-term outcomes of EUS-GBD are not well-described. We report our single-center experience of a large cohort who underwent EUS-GBD.

STUDY

Patients who underwent EUS-GBD from August 2014 to December 2022 were included in the study. Patient demographics, comorbidities, and procedure details were recorded. Patients were followed until complete stent removal, end of study period, or death. Short and long-term outcomes include technical and clinical success, stent patency, recurrent cholecystitis, cholecystectomy, and death.

RESULTS

During the study period, 128 patients were included. One hundred and one patients had benign indications for EUS-GBD, including cholecystitis and choledocholithiasis. Of those with malignant indications, 23 of 27 had distal malignant biliary obstruction. Technical and clinical successes were 95.3% and 95.1%, respectively. Stents were exchanged for 2 permanent double pigtail plastic stents in 43.0%. The mean stent patency was 421 days (488 d among those still alive) without any recurrent cholecystitis.

CONCLUSION

EUS-GBD demonstrates prolonged stent patency and minimal long-term adverse events, particularly among patients who underwent stent exchanges for permanent plastic stents. EUS-GBD is also promising for patients presenting with choledocholithiasis and biliary colic who are not surgical candidates.

Endoscopic Gallbladder Stenting to Prevent Recurrent Cholecystitis in Deferred Cholecystectomy: A Randomized Trial

BACKGROUND & AIMS

Endoscopic transpapillary gallbladder stenting (ETGS) has been proposed as one of the adjunctive treatments, apart from antibiotics, before surgery in patients with acute cholecystitis whose cholecystectomy could not be performed or was deferred. Currently, there are no comparative data on the outcomes of ETGS in those who receive and do not receive ETGS. We aimed to compare the rates of recurrent cholecystitis at 3 and 6 months in these 2 groups.

METHODS

Between 2020 and 2023, eligible acute calculous cholecystitis patients with a high probability of common bile duct stone, who were surgical candidates but could not have an early cholecystectomy during COVID-19 surgical lockdown, were randomized into groups A (received ETGS) and B (did not receive ETGS). A definitive cholecystectomy was performed at 3 months or later in both groups.

RESULTS

A total of 120 eligible patients were randomized into group A (n = 60) and group B (n = 60). In group A, technical and clinical success rates were 90% (54 of 60) and 100% (54 of 54), respectively. Based on intention-to-treat analysis, group A had a significantly lower rate of recurrence than group B at 3 months (0% [0 of 60] vs 18.3% [11 of 60]; P = .001). At 3-6 months, group A showed a nonsignificantly lower rate of recurrent cholecystitis compared to group B (0% [0 of 32] vs 10% [3 of 30]; P = .11).

CONCLUSIONS

ETGS could prevent recurrent cholecystitis in acute cholecystitis patients with common bile duct stone whose cholecystectomy was deferred for 3 months. In those who did not receive ETGS, the majority of recurrences occurred within 3 months. (Thaiclinicaltrials.org, Number TCTR20200913001).

Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Elective Cholecystectomy After Endoscopic Gallbladder Stenting for Acute Cholecystitis: A Propensity Score Matching Analysis

OBJECTIVE

To investigate the influence of endoscopic gallbladder stenting (EGBS) on subsequent cholecystectomy. We retrospectively compared the surgical outcomes of EGBS, followed by elective cholecystectomy with those of immediate cholecystectomy (IC).

PATIENTS AND METHODS

A total of 503 patients were included in this study. Patients who underwent EGBS as initial treatment for acute cholecystitis, followed by elective cholecystectomy, were included in the EGBS group and patients who underwent IC during hospitalization were included in the IC group. Propensity score matching analysis was used to compare the surgical outcomes. In addition, the factors that increased the amount of bleeding were examined by multivariate analysis after matching.

RESULTS

Fifty-seven matched pairs were obtained after propensity matching the EGBS group and the IC group. The rate of laparoscopic cholecystectomy in the EGBS versus IC groups was 91.2% versus 49.1% ( P < 0.001). The amount of bleeding was 5 mL in the EGBS versus 188 mL in the IC group ( P < 0.001). In the EGBS and IC groups, multivariate analysis of factors associated with more blood loss revealed IC (odds ratio: 4.76, 95% CI: 1.25-20.76, P = 0.022) as an independent risk factor.

CONCLUSION

EGBS as the initial treatment for acute cholecystitis and subsequent elective cholecystectomy after the inflammation has disappeared can be performed in minimally invasive procedures and safely.

Factors predicting technical failure of endoscopic transpapillary gallbladder drainage for acute cholecystitis

Objectives

Endoscopic transpapillary gallbladder drainage (ETGBD) is a highly technical procedure, but few studies have evaluated factors that predict its technical success. Therefore, in this study, we sought to identify predictors of technically successful ETGBD.

Methods

One hundred and eighty-two patients who underwent ETGBD for acute cholecystitis at our hospital were retrospectively investigated. Factors associated with technical failure were identified by focusing on clinical characteristics, anatomical features (direction of the cystic duct branch and course of the cystic duct), and procedural factors (cystic duct and gallbladder with or without contrast and cystic duct injury).

Results

The technical success rate was 84.6% (154/182) and the clinical success rate was 96.1% (148/154). The adverse event rate was 11.0% (20/182; cystic duct injury in 13 patients, pancreatitis in six, and liver abscess in one. Univariate and multivariate analyses identified the right cranial direction and spiral-type course of the cystic duct to be significant anatomical features and cystic duct injury to be a significant procedural feature contributing to the technical failure of ETGBD.

Conclusions

ETGBD is a highly practical procedure for patients with acute cholecystitis. However, difficulty is encountered in some cases because of anatomical and procedural factors. Our results suggest that ETGBD may be difficult and thus should not be performed in cases with the right cranial direction or spiral-type course of the cystic duct or those with cystic duct injury.

Safety and adverse events of EUS-guided gallbladder drainage using lumen-apposing metal stents and percutaneous cholecystostomy tubes: a systematic review and meta-analysis

BACKGROUND AND AIMS

EUS-guided gallbladder drainage using lumen-apposing metal stents (EUS-GBD-LAMSs) and percutaneous cholecystostomy for gallbladder drainage (PTGBD) are the alternative treatment modalities in high-risk surgical patients with acute cholecystitis (AC). The aim of this study was to compare the safety of these procedures for AC in surgically suboptimal candidates.

METHODS

Six studies compared the 2 groups' early, delayed, and overall adverse events; they also compared length of hospital stay, re-interventions, and re-admissions rate. A random effect model calculated odds ratios (ORs) with a 95% confidence interval (CI).

RESULTS

The 2 groups had similar early adverse events; however, EUS-GBD-LAMS was associated with a lower rate of delayed (OR, .21; 95% CI, .07-.61; P ≤ .01) and overall (OR, .43; 95% CI, .30-.61; P ≤ .01) adverse events. Patients with EUS-GBD-LAMSs had a shorter hospital stay than PTGBD.

CONCLUSIONS

EUS-GBD-LAMS is a safer option than PTGBD and is associated with a shorter hospital stay in nonsurgical candidates with AC.

Endoscopic ultrasound-guided gallbladder drainage with long-term lumen-apposing metal stent indwell: 1-year results from a prospective nationwide observational study

BACKGROUND AND AIM

This study aimed to determine safety and risk factors for adverse events (AEs) of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with long-term indwell of lumen-apposing metal stents (LAMS).

METHODS

This study is a multicenter prospective observational study on consecutive high surgical-risk patients requiring gallbladder drainage who underwent EUS-GBD with LAMS over 12 months. Centralized telephone follow-up interviews were conducted every 3 months for 1 year. Patients were censored at LAMS removal, cholecystectomy, or death. AE-free survival was determined using log-rank tests. Cumulative risks were estimated using life-table analysis.

RESULTS

Eighty-two patients were included (53.7% male, median [interquartile range] age of 84.6 [76.5-89.8] years, and 85.4% with acute cholecystitis). Technical success was achieved in 79 (96.3%), and clinical success in 73 (89%). No patient was lost to follow-up; 45 patients (54.9%) completed 1-year follow-up with in situ LAMS. Median (interquartile range) LAMS indwell time was 364 (47-367) days. Overall, 12 (14.6%) patients presented 14 AEs, including 5 (6.1%) recurrent biliary events (3 acute cholangitis, 1 mild acute pancreatitis, and 1 acute cholecystitis). Patients with pancreatobiliary malignancy had an increased risk of recurrent biliary events (33% vs 1.5%, P = 0.001). The overall 1-year cumulative risk of recurrent biliary events was 9.7% (4.1-21.8%). The 1-year risk of AEs and of severe AEs was 18.8% (11-31.2%) and 7.9% (3.3-18.2%), respectively. Pancreatobiliary malignancy was the single risk factor for recurrent biliary events; LAMS misdeployment was the strongest risk factor for AEs.

CONCLUSIONS

Long-term LAMS indwell does not increase the risk of delayed AEs following EUS-GBD.

A Review on Endoscopic Management of Acute Cholecystitis: Endoscopic Ultrasound-Guided Gallbladder Drainage and Endoscopic Transpapillary Gallbladder Drainage

A percutaneous cholecystostomy tube (PCT) is the conventionally favored nonoperative intervention for treating acute cholecystitis. However, PCT is beset by high adverse event rates, need for scheduled reintervention, and inadvertent dislodgement, as well as patient dissatisfaction with a percutaneous drain. Recent advances in endoscopic therapy involve the implementation of endoscopic transpapillary drainage (ETP-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), which are increasingly preferred over PCT due to their favorable technical and clinical success combined with lower complication rates. In this article, we provide a comprehensive review of the literature on EUS-GBD and ETP-GBD, delineating instances when clinicians should opt for endoscopic management and highlighting potential risks associated with each approach.

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.

Strategy Comparison of Endoscopic Ultrasound-Guided Gallbladder Drainage to Percutaneous Transhepatic Gallbladder Drainage, Following Failed Emergent Endoscopic Transpapillary Gallbladder Drainage

Endoscopic transpapillary gallbladder drainage (ETGBD) is recommended for patients with acute cholecystitis at high risk for surgery/percutaneous transhepatic gallbladder drainage (PTGBD). Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has higher success and mortality rates than ETGBD. Optimal endoscopic drainage remains controversial. Patients with moderate/severe acute cholecystitis and high risk for surgery/PTGBD who underwent ETGBD were enrolled. In the new-ETGBD (N-ETGBD)/traditional-ETGBD (T-ETGBD) strategy, patients in whom the initial ETGBD failed underwent rescue-EUS-GBD in the same endoscopic session/rescue-PTGBD, respectively. Therapeutic outcomes were compared. Patients who could not undergo rescue-EUS-GBD/PTGBD owing to poor general conditions received conservative treatment. Technical success was defined as successful ETGBD or successful rescue-EUS-GBD/PTGBD. Forty-one/forty patients were enrolled in the N-ETGBD/T-ETGBD groups, respectively. The N-ETGBD group had a higher, though non-significant, technical success rate compared to the T-ETGBD group (97.6 vs. 90.0%, p = 0.157). The endoscopic technical success rate was significantly higher in the N-ETGBD than in the T-ETGBD group (97.6 vs. 82.5%, p = 0.023). The clinical success/adverse event rates were similar between both groups. The hospitalization duration was significantly shorter in the N-ETGBD than in the T-ETGBD group (6.6 ± 3.9 vs. 10.1 ± 6.4 days, p < 0.001). ETGBD with EUS-GBD as a rescue backup may be an ideal hybrid drainage for emergency endoscopic gallbladder drainage in high-risk surgical patients.

Endoscopic Management of Gallbladder Disease

PURPOSE OF REVIEW

Diseases of the gallbladder can be increasingly managed through endoscopic interventions, either serving as an alternative to or obviating the need for cholecystectomy. In this review, we aim to review the most recent data on endoscopic management of the most common gallbladder diseases.

RECENT FINDINGS

The development of lumen-opposing metal stents (LAMS) marked a major shift in gallbladder management, with transmural techniques now well studied for management of cholecystitis. Endoscopic ultrasound (EUS) is also a well-developed technique for gallbladder imaging, comparable or superior to transabdominal ultrasound. Novel techniques with LAMS for gallbladder lesion/polyp resection and treatment of non-cholecystitis gallbladder diseases mark important milestones in gallbladder preservation and increasingly less invasive management of diseases of the gallbladder. There are multiple interventional endoscopic techniques that can be used to manage common gallbladder diseases including cholecystitis, cholelithiasis, gallbladder lesions/polyps, and gallbladder cancer. Ongoing development of novel therapeutic techniques holds promise for additional minimally invasive techniques in the future.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Endoscopic Ultrasound-guided Transluminal Gallbladder Drainage in Patients With Acute Cholecystitis: A Prospective Multicenter Trial

OBJECTIVE

To evaluate the safety and efficacy of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS).

BACKGROUND

For patients with acute cholecystitis who are poor surgical candidates, EUS-GBD using a LAMS is an important treatment alternative to percutaneous gallbladder drainage.

METHODS

We conducted a regulatory-compliant, prospective multicenter trial at 7 tertiary referral centers in the United States of America and Belgium. Thirty consecutive patients with mild or moderate acute cholecystitis who were not candidates for cholecystectomy were enrolled between September 2019 and August 2021. Eligible patients had a LAMS placed transmurally with 30 to 60-day indwell if removal was clinically indicated, and 30-day follow-up post-LAMS removal. Endpoints included days until acute cholecystitis resolution, reintervention rate, acute cholecystitis recurrence rate, and procedure-related adverse events (AEs).

RESULTS

Technical success was 93.3% (28/30) for LAMS placement and 100% for LAMS removal in 19 patients for whom removal was attempted. Five (16.7%) patients required reintervention. Mean time to acute cholecystitis resolution was 1.6±1.5 days. Acute cholecystitis symptoms recurred in 10.0% (3/30) after LAMS removal. Five (16.7%) patients died from unrelated causes. Procedure-related AEs were reported to the FDA in 30.0% (9/30) of patients, including one fatal event 21 days after LAMS removal; however, no AEs were causally related to the LAMS.

CONCLUSIONS

For selected patients with acute cholecystitis who are at elevated surgical risk, EUS-GBD with LAMS is an alternative to percutaneous gallbladder drainage. It has high technical and clinical success, with low recurrence and an acceptable AE rate. Clinicaltrials.gov, Number: NCT03767881.

Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage

Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.

Successful Resection of Gastric Subepithelial Lipoma Using the Bite-on-Bite Approach: Reviving Old Techniques in a Peripheral Hospital

Subepithelial lesions (SELs) are common findings in the gastrointestinal (GI) tract. They are often benign and asymptomatic but can cause symptoms in some cases. The approach to endoscopic management of these lesions depends on various factors, including associated symptoms, location, available equipment, and operator expertise. In this case report, we present a 50-year-old male with long-standing dyspepsia who was found to have a submucosal lesion in the stomach. The lesion was successfully treated using the bite-on-bite method with cold biopsy forceps. This report aims to discuss gastric subepithelial lesions and current management options, and highlight an old technique for endoscopists in the era of advanced endoscopy.

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.

Endoscopic ultrasound (EUS)-guided cholecystostomy versus percutaneous cholecystostomy (PTC) in the management of acute cholecystitis in patients unfit for surgery: a systematic review and meta-analysis

BACKGROUND AND AIM

Surgical cholecystectomy is the gold standard strategy for the management of acute cholecystitis (AC). However, some patients are considered unfit for surgery due to certain comorbid conditions. As such, we aimed to compare less invasive treatment strategies such as endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and percutaneous gallbladder drainage (PT-GBD) for the management of patients with AC who are suboptimal candidates for surgical cholecystectomy.

METHODS

A comprehensive search of multiple electronic databases was performed to identify all the studies comparing EUS-GBD versus PT-GBD for patients with AC who were unfit for surgery. A subgroup analysis was also performed for comparison of the group undergoing drainage via cautery-enhanced lumen-apposing metal stents (LAMS) versus PT-GBD. The outcomes included technical and clinical success, adverse events (AEs), recurrent cholecystitis, reintervention, and hospital readmission.

RESULTS

Eleven studies including 1155 patients were included in the statistical analysis. There was no difference between PT-GBD and EUS-GBD in all the evaluated outcomes. On the subgroup analysis, the endoscopic approach with cautery-enhanced LAMS was associated with lower rates of adverse events (RD =  - 0.33 (95% CI - 0.52 to - 0.14; p = 0.0006), recurrent cholecystitis (- 0.05 RD (95% CI - 0.09 to - 0.02; p = 0.02), and hospital readmission (- 0.36 RD (95% CI-0.70 to - 0.03; p = 0.03) when compared to PT-GBD. All other outcomes were similar in the subgroup analyses.

CONCLUSIONS

EUS-GBD using cautery-enhanced LAMS is superior to PT-GBD in terms of safety profile, recurrent cholecystitis, and hospital readmission rates in the management of patients with acute cholecystitis who are suboptimal candidates for cholecystectomy. However, when cautery-enhanced LAMS are not used, the outcomes of EUS-GBD and PT-GBD are similar. Thus, EUS-GBD with cautery-enhanced LAMS should be considered the preferable approach for gallbladder drainage for this challenging population.

Endoscopic Ultrasound-Guided Gallbladder Drainage versus Percutaneous Gallbladder Drainage for Acute Cholecystitis: A Systematic Review and Meta-Analysis

Background: Percutaneous transhepatic gallbladder drainage (PT-GBD) has been the treatment of choice for acute cholecystitis patients who are not suitable for surgery. The effectiveness of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) as an alternative to PT-GBD is not clear. In this meta-analysis, we have compared their efficacy and adverse events. Methods: We adhered to the PRISMA statement to conduct this meta-analysis. Online databases were searched for studies that compared EUS-GBD and PT-GBD for acute cholecystitis. The primary outcomes of interest were technical success, clinical success, and adverse events. The pooled odds ratio (OR) with a 95% confidence interval (CI) was calculated using the random-effects model. Results: A total of 396 articles were screened, and 11 eligible studies were identified. There were 1136 patients, of which 57.5% were male, 477 (mean age 73.33 ± 11.28 years) underwent EUS-GBD, and 698 (mean age 73.77 ± 8.7 years) underwent PT-GBD. EUS-GBD had significantly better technical success (OR 0.40; 95% CI 0.17-0.94; p = 0.04), fewer adverse events (OR 0.35; 95% CI 0.21-0.61; p = 0.00), and lower reintervention rates (OR 0.18; 95% CI 0.05-0.57; p = 0.00) than PT-GBD. No difference in clinical success (OR 1.34; 95% CI 0.65-2.79; p = 0.42), readmission rate (OR 0.34; 95% CI 0.08-1.54; p = 0.16), or mortality rate (OR 0.73; 95% CI 0.30-1.80; p = 0.50) was noted. There was low heterogeneity (I2 = 0) among the studies. Egger's test showed no significant publication bias (p = 0.595). Conclusion: EUS-GBD can be a safe and effective alternative to PT-GBD for treating acute cholecystitis in non-surgical patients and has fewer adverse events and a lower reintervention rate than PT-GBD.

Endoscopic Treatment of Acute Cholelithiasis Using AXIOS Stenting and Lithotripsy: A Case Series

The management of gallbladder diseases, including acute cholecystitis and choledocholithiasis, puts a significant strain on healthcare. The first-line treatment for acute cholecystitis is cholecystectomy. Patients who have concomitant choledocholithiasis, large stones, and/or gallstone pancreatitis may also benefit from endoscopic interventions. Endoscopic treatments may also be utilized in patients who are not surgical candidates due to underlying comorbidities. Studies examining the role of endoscopic lithotripsy in concomitant cholecystitis are limited. Herein we present a case series in which an AXIOS stent (Boston Scientific, Marlborough, Massachusetts) was placed into the gallbladder for decompression and utilized to access the gallbladder lumen to perform electrohydraulic lithotripsy in two patients.

Reduction of Lams-Related Adverse Events with Accumulating Experience in a Large-Volume Tertiary Referral Center

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMSs) are increasingly used both for on- and off-label indications. We continuously adapt our step-by-step protocol to optimize the safe deployment of LAMSs for the different indications. The aim of this study was to evaluate the impact of this approach over time.

METHODS

We conducted a single-center study on consecutive patients who underwent LAMS placement for on- and off-label indications between June 2020 and June 2022. Endpoints included technical success, clinical success and adverse event rates. We compared the results with our previously published early experience with LAMSs (N = 61), between March 2018 and May 2020.

RESULTS

This cohort consisted of 168 LAMSs in 153 patients. Almost half of them (47.6%) were placed for off-label indications (gastro-enterostomy, temporary access to the excluded stomach in patients with previous gastric bypass, drainage of postsurgical collections, stenting of short refractory gastrointestinal strictures). While the technical and clinical success rates were similar to those in our previously published cohort (97% and 93.5% versus 93.4% and 88.5%, respectively), the adverse event rate dropped from 21.3% to 8.9%.

CONCLUSIONS

Our results demonstrate the impact of a learning curve in LAMS placement, with a clinically relevant drop in LAMS-related adverse events over time.

Intermediate- to long-term outcomes of endoscopic transpapillary gallbladder stenting in patients with gallstone-related disease: a 10-year single-center experience

BACKGROUND

 Endoscopic transpapillary gallbladder stenting (ETGS) can be a bridging therapy to elective cholecystectomy or a permanent gallbladder drainage method in patients with symptomatic gallbladder disease who are awaiting cholecystectomy or are unfit for surgery, respectively. We evaluated the intermediate- to long-term outcomes of ETGS in these groups.

METHODS

 We retrospectively reviewed 234 patients (acute cholecystitis = 147), who were unfit for surgery (n = 50) or had deferred cholecystectomy (n = 184) and who underwent ETGS between 2012 and 2021. A 7-Fr, 15-cm, double-pigtail plastic stent was placed for ETGS without scheduled stent exchange. Biliary event-free rates (i. e. cholecystitis and cholangitis) were determined at 6 months, 1 year, and ≥ 2 years.

RESULTS

 Technical and clinical success rates were 84.6 % (198/234) and 97.4 % (193/198), respectively. Kaplan-Meier analysis (n = 193) showed a biliary event-free rate of 99 % (95 %CI 0.95-1.00) at 6 months, 92 % (95 %CI 0.87-0.97) at 1 year, and 76 % (95 %CI 0.65-0.93) at ≥ 2 years, during a median follow-up period of 564 days (range 200-3001 days).

CONCLUSIONS

 ETGS is an effective biliary drainage method that should be considered in selected cases with common bile duct stone where cholecystectomy could not be performed or was deferred. The biliary event-free rates of ≥ 76 % up to ≥ 2 years further support the use of ETGS in these patient groups.

What's new in the hot gallbladder: the evolving radiologic diagnosis and management of acute cholecystitis

Acute cholecystitis (AC) is a common condition and its incidence is rising. New technologies have advanced the imaging diagnosis of AC, providing more structural and functional information as well as allowing the radiologist to distinguish AC from mimics and identify complications from both the disease and its management. Dual energy CT aids in detecting gallstones and gallbladder wall enhancement, which helps to diagnose AC and identify its complications. Similarly, contrast-enhanced and non-contrast perfusion ultrasound techniques improve detection of abnormal gallbladder wall enhancement. Advances in MR imaging including hepatobiliary contrast agents aid in characterizing post-cholecystectomy complications such as bile leaks. Newer interventional techniques have also expanded the suite of options for minimally invasive management. Lumen apposing metal stents provide more options for conservative treatment in non-surgical candidates and are compared to a standard percutaneous cholecystostomy. Radiologists should be familiar with these advanced imaging methods and intervention techniques and the value they can bring to the diagnosis and management of AC.

Long-term outcomes of endoscopic ultrasound-guided gallbladder drainage versus in situ or ex situ percutaneous gallbladder drainage in real-world practice

OBJECTIVES

Many studies showed better outcomes of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) when compared with percutaneous transhepatic gallbladder drainage (P-GBD) in which most tubes were left in situ. However, no studies have directly compared EUS-GBD with P-GBD after tube removal (ex situ). We compared the long-term outcomes of EUS-GBD and ex situ or in situ P-GBD in high surgical risk patients with acute cholecystitis.

METHODS

We reviewed the records of 182 patients (EUS-GBD, n = 75; P-GBD, n = 107) who underwent gallbladder drainage. The procedural outcomes, long-term outcomes, and adverse events were compared.

RESULTS

The EUS-GBD group and the P-GBD group had similar rates of technical and clinical success. Early adverse events were less common in the EUS-GBD group (5.5% vs. 18.9%, P = 0.010). The long-term outcomes were evaluated in 168 patients (EUS-GBD, n = 67; P-GBD ex situ, n = 84; P-GBD in situ, n = 17). The rate of cholecystitis recurrence in the EUS-GBD group (6.0%) was similar to that in the P-GBD ex situ group (9.6%, P = 0.422), but significantly lower than that in the P-GBD in situ group (23.5%, P = 0.049). P-GBD in situ was a significant predictor of recurrent cholecystitis (hazard ratio 14.6; 95% confidence interval 2.9-72.8).

CONCLUSION

The long-term recurrence rate of acute cholecystitis in patients who underwent EUS-GBD was comparable to that in patients whose P-GBD could be removed. However, patients in whom P-GBD could not be removed showed higher rates of recurrent cholecystitis than patients with EUS-GBD.

Endoscopic ultrasound in the management of acute cholecystitis

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is increasingly utilised for patients with acute cholecystitis who are high-risk candidates for surgery. The technique to perform EUS-GBD has evolved and matured over the last two decades since EUS-GBD was first described in 2007 using a nasobiliary catheter. Compared to percutaneous gallbladder drainage (PT-GBD), EUS-GBD offers benefits of shorter hospitalisation stay and lesser procedural pain and need for reintervention. The purpose of this review is to provide an updated review of the equipment and techniques available for EUS-GBD, outcomes of the procedure and how it compares against endoscopic transpapillary drainage (ET-GBD), PT-GBD and laparoscopic cholecystectomy. Controversies surrounding the procedure will also be discussed.

Endoscopic Management of Acute Cholecystitis

Endoscopic drainage of the gallbladder for acute cholecystitis can be performed with the transpapillary method or endoscopic ultrasound (EUS)-guided method. EUS-guided gallbladder drainage (EUS-GBD) is gaining popularity as the treatment of choice for acute cholecystitis in patients who are deemed high-risk for cholecystectomy (CCY). It provides an alternative to percutaneous drainage and laparoscopic CCY in these patients. With the development of lumen-apposing metal stents (LAMS), the procedure is associated with high rates of technical and clinical success with low rates of adverse events (AEs). The aim of this article is to provide an overview of the current status of EUS-GBD including the indications, techniques, stent systems in-use, and how the procedure compares to conventional techniques are outlined. Furthermore, the feasibility of cholecystoscopy and advanced gallbladder interventions is explored. Finally, a comparison in outcomes of EUS-GBD versus laparoscopic CCY is provided giving some initial data in support of the procedure as an alternative to surgery in a selected group of patients.

Effectiveness and Safety of Lumen-Apposing Metal Stents in Endoscopic Interventions for Off-Label Indications

BACKGROUND

Although released only for drainage of pseudocyst and walled-off necrosis (WON) with ≤ 30% solid debris, the utilization of lumen-apposing metal stent (LAMS) in "real-world" practice has deviated from approved indications. We evaluated the contemporary use of LAMS and associated clinical, procedural outcomes in the setting of a tertiary referral center in the USA.

METHODS

Data from 303 consecutive patients who underwent LAMS placement were analyzed. Outcomes included technical and clinical success rates and adverse events.

RESULTS

Of 303 patients, 190 (62.7%) received LAMS for off-label indications. The latter included gallbladder drainage (n = 56, 18.5%), gastroenterostomy (n = 52, 17.2%), treatment of gastrointestinal strictures (n = 37, 12.2%), biliary drainage (n = 20, 6.6%), temporary gastric access for endoscopy (n = 13, 4.3%), symptomatic WON with > 30% solid debris (n = 8, 2.6%), and miscellaneous (n = 4, 1.3%). Technical success rates in the on- and off-label arm were 98.2% and 95.8%, respectively (P = .331; 95% CI 0.08 to 1.96). Clinical success rates in the on- and off-label arm were 89.4% and 83.2%, respectively (P = .137; 95% CI 0.28 to 1.19). The rate of adverse events was 20.5% (n = 39) in the off-label arm and 16.8% (n = 19) in the on-label arm (P = .242; 95% CI 0.69 to 2.34).

CONCLUSION

Off-label use of LAMS out-numbered on-label use in our practice. The safety profile between the groups was similar and with the exception of refractory stricture treatment, efficacy was comparable.

Therapeutic endoscopic ultrasound

Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.