Hybrid procedure combining endoscopic gallbladder lavage and internal drainage with elective cholecystectomy for acute cholecystitis: A prospective pilot study (The BLADE study)

Usefulness of a One-step Semi-deployment Flushing and Stenting Technique in Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis (With Video)

Objectives

Endoscopic transpapillary gallbladder stenting (EGBS) has demonstrated high technical and clinical success rates in endoscopic transpapillary gallbladder drainage (ETGBD) for acute cholecystitis. The effectiveness of a 5-Fr endoscopic naso-gallbladder drainage (ENGBD) tube for flushing and the internal fistula technique after tube cutting has also been reported. We developed an alternative one-step semi-deployed flushing and stenting technique for EGBS using a 7-Fr pigtail stent that avoids tube resection and evaluated its effectiveness and safety compared with that of endoscopic nasogastric gallbladder drainage.

Methods

We retrospectively evaluated 30 patients who underwent ETGBD for acute cholecystitis between April 2023 and November 2024.

Results

The technical and clinical success rates of the one-step semi-deployment flushing and stenting techniques were 95.2% (20/21) and 100% (20/20), respectively. No adverse events were reported. The procedure time did not differ significantly from that of ENGBD.

Conclusions

EGBS using one-step semi-deployment flushing and stenting is a simple and effective treatment for acute cholecystitis in patients with ETGBD.

Research progress in the treatment of gallstones with laparoscopic and endoscopic surgery: a narrative review

Cholelithiasis, the formation of stones in the gallbladder, is a common surgical condition with an increasing incidence. Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallstones due to its favorable outcomes. However, with increasing recognition of the gallbladder's importance, this procedure no longer aligns with patients' desire to preserve the organ. Technological advancements and surgical innovations have led to emerging approaches such as natural orifice transluminal endoscopic surgery (NOTES), robot-assisted laparoscopic cholecystectomy, and cholangioscopy. This narrative review examines the current landscape of surgical interventions for gallstones, highlighting both gallbladder-preserving and removal approaches, and aims to provide insight into their respective outcomes and clinical implications.

Percutaneous and endoscopic transpapillary cholecystoduodenal stenting in acute cholecystitis-A viable long-term option in high-risk patients?

BACKGROUND

The prolonged use of percutaneous cholecystostomy tubes (PCTs) in patients with acute cholecystitis, deemed inoperable, is fraught with complications. Transpapillary cholecystoduodenal stenting (TCDS) is an alternative technique that restores the physiologic outflow of bile, avoiding the need for an external drain. However, the long-term safety and efficacy of this approach remain unclear. We sought to prospectively assess the safety and efficacy of this procedure, performed via percutaneous or endoscopic approach, in high-risk patients presenting with acute cholecystitis.

METHODS

This prospective study included consecutive patients with acute cholecystitis and long-lasting, prohibitive surgical risk, in whom TCDS was offered at two partnering tertiary care centers between August 1, 2018, and December 31, 2022. Patients with a need for endoscopic retrograde cholangiopancreatography (ERCP) underwent ERCP-guided TCDS. In patients without a need for ERCP, a temporary PCT was followed by fluoroscopic-guided TCDS 4 weeks to 6 weeks later. Interval cholecystectomy was performed in patients who became surgical candidates later. All patients were followed up until January 1, 2023.

RESULTS

Transpapillary cholecystoduodenal stenting was successful in 67 (percutaneous in 45/50; endoscopic in 22/23) of 73 patients (92%) attempted. Over a median follow-up period of 17 months (7, 26), 10 patients (15%) developed stent blockage or migration; all but two had their stent successfully replaced. Five patients (7%) developed mild, self-limited pancreatitis. Five (7%) patients underwent interval cholecystectomy at a median time of 7 months.

CONCLUSION

Transpapillary cholecystoduodenal stenting is a safe and promising definitive alternative to chronic PCT in high-risk patients with acute cholecystitis that eliminates the discomfort and complications of long-term external drainage.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

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.

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.

Endoscopic internalization by cutting versus removal of the endoscopic transpapillary naso-gallbladder drainage tube in preoperative management of acute cholecystitis: A retrospective multicenter cohort study

BACKGROUND

Endoscopic transpapillary naso-gallbladder drainage (ENGBD) has been reported to be an effective treatment option for acute cholecystitis. At our institution, ENGBD was first placed for external fistula management, and endoscopic internalization by cutting was performed, shifting to endoscopic transpapillary gallbladder stenting (EGBS) after improvement of cholecystitis. However, there has been no comparative study to define which preoperative management is better: converting ENGBD to EGBS or removing ENGBD. The study aimed to compare the incidence rate of the late adverse events (AEs) related to biliary system between shifting from ENGBD to EGBS and removal of ENGBD.

METHODS

We retrospectively studied 122 patients who underwent ENGBD for acute cholecystitis between January 2010 and October 2022. The patients were divided into two groups: the cutting group (converting ENGBD to EGBS) and the removal group (removal of ENGBD). The short and late clinical outcomes were compared between groups.

RESULTS

Endoscopic transpapillary naso-gallbladder drainage was successfully placed in 78.6% (96/122), and elective cholecystectomy was performed in 31 and 36 patients in the cutting and removal groups, respectively. The cumulative late-AE rates were 6.4% and 33.3% (p = .007), with a median waiting period for elective cholecystectomy of 58 and 33 days (p = .390) in the cutting and removal groups, respectively. In the multivariate analysis, only endoscopic internalization by cutting was an independent factor affecting late AEs.

CONCLUSION

Endoscopic internalization by cutting ENGBD after the resolution of acute cholecystitis was considered effective in reducing the risk of late AEs during the waiting period for an elective cholecystectomy.

Endoscopic Internalization by Cutting the Endoscopic Transpapillary Nasogallbladder Drainage Tube in Management of Acute Cholecystitis: A Retrospective Multicenter Cohort Study

BACKGROUND

Both endoscopic nasogallbladder drainage (ENGBD) and endoscopic gallbladder stenting (EGBS) are effective management for acute cholecystitis, although ENGBD can cause discomfort due to its nature of external drainage. Converting ENGBD to EGBS after improvement of cholecystitis might be one treatment strategy. The drainage tube of ENGBD could be endoscopically cut inside the stomach to convert to internal drainage without additional endoscopic retrograde cholangiography (ERCP).

AIMS

To evaluate the feasibility, efficacy and safety of endoscopic internalization by cutting an ENGBD tube for acute cholecystitis.

METHODS

Twenty-one patients who underwent endoscopic internalization by cutting the ENGBD tube were enrolled in this study. We initially placed an ENGBD tube for gallbladder lavage and continuous drainage. After improvement of cholecystitis, the tube was cut in the stomach by esophagogastroduodenoscopy (EGD) and placed as EGBS until surgery.

RESULTS

The technical success rate of this procedure was 90.5% (19/21), and the clinical success rate was 100% (19/19). The median procedural time was 5 min (range: 2-14 min). Procedural-related adverse events (AEs) were observed in two patients where the tip of the ENGBD tube migrated into the common bile duct from the gallbladder during the procedure in both. During the waiting period for elective surgery, no AEs were identified, except for stent migration without symptoms in one patient (4.7%).

CONCLUSION

Endoscopic internalization by cutting the ENGBD tube after improvement of cholecystitis could be an effective and safe treatment option for preventing recurrent cholecystitis in the waiting period until cholecystectomy.

Feasibility of a Single Pigtail Stent Made by Cutting a Nasobiliary Drainage Tube in Endoscopic Transpapillary Gallbladder Stenting for Acute Cholecystitis

Background and objective

In this study, we aimed to evaluate the efficacy and safety of a single pigtail stent made by cutting a nasobiliary drainage tube (NBD stent) by comparing the clinical outcomes of using an NBD stent and those of using a ready-made double pigtail stent (RDP stent) in endoscopic gallbladder stenting (EGBS) for acute cholecystitis.

Materials and methods

This was a single-center retrospective study involving 20 cases that had technical success with EGBS for acute cholecystitis; the patients were divided into two groups: those using NBD stent (NBD group) and those using RDP stent (RDP group). The baseline characteristics and clinical outcomes were compared between the two groups.

Results

There were 13 patients in the NBD group and seven in the RDP group. The rates of clinical success (NBD group: 92% vs. RDP group: 100%, p=0.45) did not differ significantly between the groups. Regarding adverse events, gallbladder perforation occurred in one case in the NBD group; however, no other adverse events occurred in either group (NBD group: 7.7% vs. RDP group: 0%, p=0.45). The stent patency periods did not differ significantly between the groups [NBD group: 43 (12-64) days vs. RDP group: 97 (58-215) days, p=0.17]. The stent patency period in cases of long-term stent placement after EGBS was 1,381 days and 1,579 days in the NBD group and 305 days in the RDP group, respectively.

Conclusion

NBD stents are considered as effective as RDP stents in EGBS for acute cholecystitis. They are highly versatile and can be used for both bridging to surgery and long-term stent placement.

Permanent endoscopic transpapillary gallbladder drainage using a novel spiral stent (IYO-stent)

BACKGROUND AND AIM

Endoscopic transpapillary gallbladder drainage (ETGBD) is widely performed. However, there is no consensus on the appropriate diameter, length, and shape of the stent that should be used in this procedure. In addition, there are limited data on the outcomes of permanent ETGBD. In our facility, a stent with a novel spiral structure (IYO-stent) is permanently placed in patients with acute cholecystitis who are not indicated for surgery. This study examined the efficacy and safety of the IYO-stent in cases of permanent ETGBD.

METHODS

We retrospectively examined patients who underwent permanent ETGBD using the IYO-stent from April 2018 to December 2020.

RESULTS

Eleven patients were included in this study. The technical success and the clinical success rate were 91%. One patient had a post-procedure adverse event (post-endoscopic sphincterotomy bleeding). Within the median observation period of 312 days (range: 109-742), late adverse events, including cholangitis (n = 1) and incomplete stent migration (n = 1), were observed. However, none of the patients experienced cholecystitis relapse.

CONCLUSION

Permanent ETGBD with IYO-stent is an effective treatment for the patients with acute cholecystitis who are not indicated for surgery.

Gallbladder-preserving cholecystolithotomy

INTRODUCTION

Cholecystectomy is the preferred option for symptomatic gallstones. Gallbladder-preserving cholecystolithotomy (GPC) is proposed to satisfy the specific surgical patients with high-risks, biliary deformity and suffered from concomitant gallstone and choledocholithiasis.

AREAS COVERED

This review summarizes and compares the various GPC operations for cholelithiasis in some specific cases.

EXPERT OPINION

Transmural GPC mainly focuses on the gallstones, including endoscopic minimally invasive cholecystolithotomy (EMIC)-, natural orifice transluminal endoscopic surgery-, and endoscopic ultrasonography (EUS)-GPC. These GPC procedures potentially preserve gallbladder integrity and function after clearance of gallstones. Additionally, transmural GPC may overcome the disadvantages of cholecystectomy, including cosmetic considerations and postoperative complications. However, the stone recurrence rate of EMIC varies greatly from 4.92% to 40.0%, and based on limited studies, long-term adverse events due to gallbladder mucosa and natural lumen injury are largely unknown in transmural GPC. Thus, transmural GPC may be an alternative to cholecystectomy for surgical patients with high-risks and abnormal biliary anatomy. Endoscopic retrograde cholangiopancreatography-based transcystic GPC may be promising for some specific patients with concomitant gallstones and choledocholithiasis, since gallbladder integrity and function may be completely preserved as the gallbladder wall was hardly injured and the function of sphincter of Oddi was retained.

Incidence and management of cystic duct perforation during endoscopic transpapillary gallbladder drainage for acute cholecystitis

BACKGROUND AND AIM

Evidence regarding the incidence and clinical outcome of cystic duct perforation (CDP) during endoscopic transpapillary gallbladder drainage (ETGBD) is inadequate. The present study aimed to evaluate the incidence and management of CDP during ETGBD.

METHODS

Between March 2011 and December 2019, 249 patients underwent initial ETGBD for acute cholecystitis. The incidence of CDP was retrospectively examined and the outcomes between the CDP and non-CDP groups were compared.

RESULTS

CDP during ETGBD occurred in 23 (9.2%) of 249 patients (caused by guidewire in 15 and cannula in 8). ETGBD was successful in 10 patients following CDP. In 13 patients who failed ETGBD, 11 underwent bile duct drainage during the same session; nine patients underwent gallbladder decompression by other methods, such as percutaneous drainage. Clinical resolution for acute cholecystitis was achieved in 20 patients, and no bile peritonitis was noted. ETGBD technical success rates (45.3% vs. 91.2%, p < 0.001), ETGBD procedure times (66.5 vs. 54.8 min, p = 0.041), and hospitalization periods (24.5 vs. 18.7 days, p = 0.028) were significantly inferior in the CDP group (n = 23) compared with the non-CDP group (n = 216). There were no differences in clinical success and adverse events other than CDP between both groups.

CONCLUSIONS

Cystic duct perforation reduced the ETGBD technical success rate. However, even in patients with cystic duct perforation, an improvement of acute cholecystitis was achieved by subsequent successful ETGBD or additional procedures, such as percutaneous drainage.

Endoscopic therapies for gallbladder drainage

BACKGROUND AND AIMS

Endoscopic management of acute cholecystitis has expanded in patients who are considered nonoperative candidates. Traditionally managed with percutaneous cholecystostomy (PC), improvement in techniques and devices has led to increased use of endoscopic methods for gallbladder drainage. This document reviews technical aspects of endoscopic transpapillary gallbladder drainage (ET-GBD) and EUS-guided GBD (EUS-GBD) as well as their respective technical/clinical success and adverse event rates. Available comparative data are also reviewed among nonsurgical gallbladder drainage techniques (PC, ET-GBD, and EUS-GBD).

METHODS

The MEDLINE database was searched through March 2021 for relevant articles by using keywords including "acute cholecystitis," "interventional EUS," "percutaneous cholecystostomy," "transpapillary gallbladder drainage," "EUS-guided gallbladder drainage," "lumen-apposing metal stent," "gallbladder stenting," and "endoscopic gallbladder drainage." The manuscript was drafted by 2 authors and reviewed by members of the American Society for Gastrointestinal Endoscopy Technology Committee and subsequently by the American Society for Gastrointestinal Endoscopy Governing Board.

RESULTS

Multiple studies have demonstrated acceptable outcomes comparing PC and both endoscopic gallbladder drainage techniques, ET-GBD and EUS-GBD. Published data suggest that endoscopic gallbladder drainage techniques may be associated with lower rates of adverse events and improved quality of life. However, there are important clinical considerations for choosing among these treatment options, requiring a multidisciplinary and collaborative approach to therapeutic decision-making in these patients.

CONCLUSIONS

The implementation of EUS-GBD and ET-GBD in high-risk surgical patients with acute cholecystitis may result in favorable outcomes when compared with PC. Further improvements in techniques and training should lead to more widespread acceptance and dissemination of these treatment options.

Efficacy and safety of endoscopic transpapillary gallbladder drainage in acute cholecystitis: An updated meta-analysis

BACKGROUND

Percutaneous transhepatic gallbladder drainage has been the most frequently performed treatment for acute cholecystitis for patients who are not candidates for surgery. Endoscopic transpapillary gallbladder drainage (ETGBD) has evolved into an alternative treatment. There have been numerous retrospective and prospective studies evaluating ETGBD for acute cholecystitis, though results have been variable.

AIM

To evaluate the efficacy and safety of ETGBD in the treatment of inoperable patients with acute cholecystitis.

METHODS

We performed a systematic review of major literature databases including PubMed, OVID, Science Direct, Google Scholar (from inception to March 2021) to identify studies reporting technical and clinical success, and post procedure adverse events in ETGBD. Weighted pooled rates were then calculated using fixed effects models for technical and clinical success, and post procedure adverse events, including recurrent cholecystitis.

RESULTS

We found 21 relevant articles that were then included in the study. In all 1307 patients were identified. The pooled technical success rate was 82.62% [95% confidence interval (CI): 80.63-84.52]. The pooled clinical success rate was found to be 94.87% (95%CI: 93.54-96.05). The pooled overall complication rate was 8.83% (95%CI: 7.42-10.34). Pooled rates of post procedure adverse events were bleeding 1.03% (95%CI: 0.58-1.62), perforation 0.78% (95%CI: 0.39-1.29), peritonitis/bile leak 0.45% (95%CI: 0.17-0.87), and pancreatitis 1.98% (95%CI: 1.33-2.76). The pooled rates of stent occlusion and migration were 0.39% (95%CI: 0.13-0.78) and 1.3% (95%CI: 0.75-1.99) respectively. The pooled rate of cholecystitis recurrence following ETGBD was 1.48% (95%CI: 0.92-2.16).

CONCLUSION

Our meta-analysis suggests that ETGBD is a feasible and efficacious treatment for inoperable patients with acute cholecystitis.

Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis

The mainstay of management of acute cholecystitis has been surgical, with percutaneous gallbladder drainage in patients deemed high risk for surgical intervention. Endoscopic management of acute cholecytitis with transpapillary and transmural drainage of the gall bladder is emerging as a viable alternative in high-risk surgical patients. In this article, we discuss the background, current status, technical challenges and strategies to overcome them, adverse events, and outcomes of endoscopic transpapillary gallbladder drainage for management of acute cholecystitis.

Permanent endoscopic gallbladder stenting versus removal of gallbladder drainage, long-term outcomes after management of acute cholecystitis in high-risk surgical patients for cholecystectomy: Multi-center retrospective cohort study

BACKGROUND

Endoscopic transpapillary gallbladder drainage (EGBD) has been reported as an effective gallbladder drainage treatment option for acute cholecystitis in high-risk surgical patients. However, the long-term outcomes such as cholecystitis' recurrence rate after placement of EGB stenting (EGBS) have not been well studied yet.

AIMS

The aim of the present study was to compare the long-term outcome of EGBS and removal of gallbladder drainage after percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic nasogallbladder drainage (ENGBD) for acute cholecystitis in high-risk surgical patients and clarify the usefulness of long-term placement of EGBS.

METHODS

We retrospectively studied 180 high-risk surgical patients with acute cholecystitis between January 2010 and December 2018. The patients were divided into two groups: EGBS group (long-term placement of EGBS) or Removal group (removal of drainage tube after PTGBD or ENGBD). Clinical outcomes, including long-term results, were compared between the groups.

RESULTS

The cumulative late adverse event (AE) rates were 5.0% and 22.1% in the EGBS and Removal group (P = .002), with a median follow-up period of 375 and 307 days in the two groups, respectively. The cumulative cholecystitis recurrence rate was 5.0% (2/40) in the EGBS group and 16% (21/131) in the Removal group (P = .024), respectively. In the multivariate analysis for late AE, only EGBS was an independent risk factor with a decreasing value.

CONCLUSION

The permanent EGBS in high-risk surgical patients with acute cholecystitis was considered effective in reducing the risk of late AE.

Laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting for acute cholecystitis: a pilot study of surgical feasibility

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is indicated for patients with acute cholecystitis (AC) who are not indicated for urgent surgery, but external tubes reduce quality of life (QOL) while waiting for elective surgery. The objective of the present study was to investigate the feasibility of laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting (ETGBS) comparing with after PTGBD.

METHODS

Intraoperative and postoperative outcomes of patients with ETGBS and PTGBD were retrospectively compared.

RESULTS

Eighteen ETGBS and ten PTGBD patients were compared. Differences in the duration of ETGBS and PTGBD [median 209 min (range 107-357) and median 161 min (range 130-273), respectively, P = 0.10], median blood loss [ETGBS 2 (range 2-180 ml) and PTGBD 24 (range 2-100 ml), P = 0.89], switch to laparotomy (ETGBS 11% and PTGBD 20%, P = 0.52), and median postoperative hospital stay [ETGBS 8 (range 4-24 days) and ETGBS 8 (range 4-16 days), P = 0.99]. Thickening of the cystic duct that occurred in 60% of the ETGBS patients and none of the PTGBD patients (P = 0.005) interfered with closure of the duct by clipping. No obstruction occurred in ETGBS patients.

CONCLUSION

ETGBS did not make laparoscopic cholecystectomy less feasible than after PTGBD. This is a pilot study, and further investigations are needed to validate the results of the present study.

Endoscopic ultrasound-guided gallbladder drainage with a combined internal and external drainage tubes for acute cholecystitis

BACKGROUND AND AIM

Lumen-apposing metal stent is widely used for endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) nowadays but not approved in many countries and might be unsuitable for elective laparoscopic cholecystectomy (LC) because of its large enterocholecysto fistula. A combination of double pigtail plastic stent (DPPS) and naso-cystic tube (NCT) could overcome these problems. The aim of this study was to estimate the efficacy and safety of this method in patients with acute cholecystitis unfit for urgent cholecystectomy both as bridge to surgery and palliation.

METHODS

This was a prospective, single-center feasibility study. EUS-GBD was performed with a 7Fr DPPS followed by an NCT placement. NCT was removed after 1 week. LC was performed 2 or 3 months after EUS-GBD in eligible patients. In patients who did not underwent cholecystectomy, DPPS was left in place.

RESULTS

Twenty-three patients were enrolled. Both technical and clinical success rates were 96% (22/23). Early adverse events rate was 13% (3/23), including one bile peritonitis, one intraperitoneal abscess, and one melena. LC was attempted in 12 patients, and conversion to open cholecystectomy was required in three (25%). Neither recurrence of cholecystitis nor late adverse event occurred during 6 months of follow up in 10 patients who did not undergo cholecystectomy.

CONCLUSION

EUS-GBD with a combination of DPPS and NCT is considered an effective and safe technique both as bridge to surgery and palliation.

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

BACKGROUND AND AIM

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an emerging option for acute cholecystitis in non-surgical candidates. Combining endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct stones with EUS-GBD in a single session might become a non-surgical management strategy to comprehensively treat gallstone disease in selected patients.

METHODS

Single-center retrospective cohort study comparing outcomes between EUS-GBD alone (group A) and single-session ERCP combined with EUS-GBD (group B). Consecutive patients who underwent EUS-GBD with a lumen-apposing metal stent (LAMS) between June 2011 and August 2018 were analyzed. Exclusion criteria were subjects included in randomized clinical trials, patients who had had ERCP within 5 days of EUS-GBD, patients in whom ERCP or EUS-GBD was carried out for salvage of one or the other procedure, and patients who underwent concurrent EUS-guided biliary drainage.

RESULTS

One hundred and nine consecutive patients underwent EUS-GBD with LAMS during the study period. Seventy-one patients satisfied the inclusion criteria and 34 patients were in group A and 37 in group B. Baseline characteristics were similar in both groups. There were no significant differences in technical (97.1% vs 97.3%; P = 0.19) and clinical success rates (88.2% vs 94.6%; P = 0.42) of EUS-GBD in group A versus group B. Rate of adverse events was similar in both groups, five (14.7%) in group A versus five (13.5%) in group B.

CONCLUSIONS

Single-session EUS-GBD combined with ERCP has comparable rates of technical and clinical success to EUS-GBD alone. A combined EUS-GBD and ERCP procedure does not appear to increase adverse events and makes possible comprehensive treatment of gallstone disease by purely endoscopic means.

Endoscopic transpapillary gallbladder stenting using a newly designed plastic stent for acute cholecystitis

Background and study aims Biliary plastic stents are generally substituted for gallbladder stents in endoscopic transpapillary gallbladder stenting (EGBS), there is no sufficient evidence about what type of plastic stent is suitable. We examined outcomes of EGBS using standard biliary stents and a novel stent for acute cholecystitis and evaluated the efficacy of the novel stent.

Patients and methods Seventy patients with acute cholecystitis in whom EGBS was performed were evaluated retrospectively. We performed EGBS in 23 patients using the novel stent (novel stent group) and 47 patients using standard biliary stents (pigtail: 35, straight: 12) (control group). In the two groups, we examined outcomes of EGBS.

Results There were no significant differences in patient backgrounds or rates of technical success, clinical success, or early adverse events (AE) between the novel stent group and the control groups. However, rates of late AEs were 4.3 % in the novel stent group (liver abscess: 1) and 40.4 % in the control group (stent migration: 15, recurrence of cholecystitis: 4), indicating a significantly higher rate in the control group (P = 0.004). The rate of stent migration was significantly higher in the control group (P = 0.006). Multivariate analysis identified a straight type stent as the risk factor for stent migration (odds ratio: 8.81, 95 % confidence interval: 1.66 – 46.83).

Conclusions The novel stent had significantly lower rates of late AEs and stent migration. Thus, for long-term stent placement, the novel stent was more effective than traditional biliary stents.