Clinical efficacy and safety of endoscopic ultrasound-guided gallbladder drainage replacement of percutaneous drainage: A multicenter retrospective study

Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives

In recent years, therapeutic endoscopy has become a fundamental tool in the management of gallbladder diseases in light of its minimal invasiveness, high clinical efficacy, and good safety profile. Both endoscopic transpapillary gallbladder drainage (TGBD) and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) provide effective internal drainage in patients with acute cholecystitis unfit for cholecystectomy, avoiding the drawbacks of external percutaneous gallbladder drainage (PGBD). The availability of dedicated lumen-apposing metal stents (LAMS) for EUS-guided transluminal interventions contributed to the expansion of endoscopic therapies for acute cholecystitis, making endoscopic gallbladder drainage easier, faster, and hence more widely available. Moreover, EUS-GBD with LAMS opened the possibility of several cholecystoscopy-guided interventions, such as gallstone lithotripsy and clearance. Finally, EUS-GBD has also been proposed as a rescue drainage modality in malignant biliary obstruction after failure of standard techniques, with encouraging results. In this review, we will describe the TBGD and EUS-GBD techniques, and we will discuss the available data on clinical efficacy in different settings in comparison with PGBD. Finally, we will comment on the future perspectives of EUS-GBD, discussing the areas of uncertainty in which new data are more strongly awaited.

Endoscopic Gallbladder Drainage Conversion versus Conservative Treatment Following Percutaneous Gallbladder Drainage in High-Risk Surgical Patients

Background/Aims

There are no consensus guidelines for patients with acute cholecystitis undergoing percutaneous cholecystostomy who are unfit for interval cholecystectomy. The current study aimed to compare the clinical outcomes of endoscopic gallbladder drainage, i.e. conversion from percutaneous cholecystostomy (including endoscopic transpapillary gallbladder stenting and endoscopic ultrasound-guided gallbladder drainage), and conservative treatment after percutaneous cholecystostomy tube removal.

Methods

This retrospective review included patients who underwent percutaneous cholecystostomy for acute cholecystitis between January 2017 and December 2020. Consecutive patients who underwent endoscopic gallbladder drainage or percutaneous cholecystostomy tube removal without interval cholecystectomy were included. Outcome measures included recurrent acute cholecystitis and unplanned readmission due to gallstone-related diseases.

Results

During the study period, 238 patients were selected (63 underwent endoscopic gallbladder drainage conversion and 175 underwent conservative treatment). Patients who underwent endoscopic gallbladder drainage conversion had lower rates of recurrent acute cholecystitis (3 [4.76%] vs 31 [17.71%], p=0.012) and unplanned readmission due to gallstone-related diseases (6 [9.52%] vs 40 [22.86%], p=0.022) than those who underwent conservative treatment following percutaneous cholecystostomy tube removal. In the univariate and multivariate analyses, calculus cholecystitis (odds ratio, 13.75; 95% confidence interval, 1.83 to 102.83; p=0.011) and conversion of endoscopic gallbladder drainage (odds ratio, 0.23; 95% confidence interval, 0.06 to 0.78; p=0.019) were significant predictive factors for recurrent acute cholecystitis.

Conclusions

Endoscopic gallbladder drainage conversion led to more favorable outcomes than conservative treatment after percutaneous cholecystostomy tube removal. Therefore, endoscopic gallbladder drainage conversion may be considered a promising treatment option for patients undergoing percutaneous cholecystostomy who are at a high surgical risk.

EUS-Guided Gallbladder Drainage Using a Lumen-Apposing Metal Stent for Acute Cholecystitis: Results of a Nationwide Study with Long-Term Follow-Up

BACKGROUND

Although endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using lumen-apposing metal stents (LAMS) has become one of the treatments of choice for acute cholecystitis (AC) in fragile patients, scant data are available on real-life settings and long-term outcomes.

METHODS

We performed a multicenter retrospective study including EUS-guided GBD using LAMS for AC in 19 Italian centers from June 2014 to July 2020. The primary outcomes were technical and clinical success, and the secondary outcomes were the rate of adverse events (AE) and long-term follow-up.

RESULTS

In total, 116 patients (48.3% female) were included, with a mean age of 82.7 ± 11 years. LAMS were placed, transgastric in 44.8% of cases, transduodenal in 53.3% and transjejunal in 1.7%, in patients with altered anatomy. Technical success was achieved in 94% and clinical success in 87.1% of cases. The mean follow-up was 309 days. AEs occurred in 12/116 pts (10.3%); 8/12 were intraprocedural, while 1 was classified as early (<15 days) and 3 as delayed (>15 days). According to the ASGE lexicon, two (16.7%) were mild, three (25%) were moderate, and seven (58.3%) were severe. No fatal AEs occurred. In subgroup analysis of 40 patients with a follow-up longer than one year, no recurrence of AC was observed.

CONCLUSIONS

EUS-GBD had high technical and clinical success rates, despite the non-negligible rate of AEs, thus representing an effective treatment option for fragile patients.

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.

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.

Long-Term Safety, Efficacy, Indications, and Criteria of Arteriovenous Fistula Ligation Following Kidney Transplant: A Patient-Driven Approach

OBJECTIVES

In patients with end-stage renal disease, arteriovenous fistulas are the standard of care to ensure long-term vascular access. Recent studies suggest some long-term posttransplant cardiac benefits and quality of life improvements in kidney transplant recipients due to arteriovenous fistula ligation. However, there are no guidelines regarding arteriovenous fistula management after transplant. Our study objective was to evaluate the long-term safety of arteriovenous fistula ligation and the frequency of returning to hemodialysis after ligation.

MATERIALS AND METHODS

Retrospective chart review from February 2014 to December 2020 identified 578 adult patients who underwent successful kidney transplant at our center. Of these patients, 47 underwent subsequent arteriovenous fistula ligation. Both medically driven and patient-driven cases were assessed and approved by a transplant nephrology team with regard to allograft function and ligation suitability.

RESULTS

Our results showed that, of the 47 renal transplant patients, 70.2% chose to undergo arteriovenous fistula ligation due to aneurysmal formation, 44.7% due to pain, and 14.9% due to high-output heart failure. In total, 68.1% of arteriovenous fistula ligations performed were primarily patient driven. There was an average follow-up of 2.9 years after ligation, with 1 unrelated reoperation and no returns to dialysis for all patients who underwent arteriovenous fistula ligation.

CONCLUSIONS

In our study, the long-term risks of surgical complications and allograft impairment after ligation were negligible. As a result of our current findings and known positive cardiovascular benefit, patient-driven arteriovenous fistula ligation after kidney transplant should be routinely considered in patients with stable allograft function.

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.

Diagnostic and Therapeutic Indications for Endoscopic Ultrasound (EUS) in Patients with Pancreatic and Biliary Disease—Novel Interventional Procedures

There is growing evidence supporting the substantial, essential and indispensable role of endoscopic ultrasound (EUS) as a key diagnostic armamentarium for upper GI oncologic surgery. Well described in countless publications, EUS holds that position in gastroenterological expert centers all over Europe. Despite its undisputable contributions to oncologic upper GI surgery, the availability of this technique at the expert level shows up in an irregular spread pattern. Endoscopic ultrasound’s primary use during the first few years after its creation was the detection of pancreatic cancer. From then on, EUS developed in different directions, becoming a diagnostic tool that increasingly better defines its status as a method of minimally invasive therapeutic applications and a useful addition to surgical options. As a result, several surgical interventions could even be replaced by ultrasound-targeted interventions. This process took place in just a few years and was made possible by technical development that sensibly combined high-resolution ultrasound with therapeutic endoscopy. The present article will serve to cover the most prevalent uses with supporting data considering the growing list of suggested indications for EUS while also examining cutting-edge initiatives that might soon become the standard of clinical practice. Endoscopic centers with high expertise are needed to train future experts in the growing field of EUS interventions.

Ex vivo comparison of electrocautery-enhanced delivery of lumen-apposing metal stents matching electrosurgical workstations during EUS-guided gallbladder drainage

Background and Objectives

EUS-guided gallbladder drainage (EUS-GBD) has become one of the recommended treatments for patients with high-risk acute cholecystitis. However, the gallbladder reportedly collapsed due to bile leakage, which was a disadvantage that affects the surgical success rate. Different electrocautery-enhanced delivery of the lumen-apposing metal stents (ECE-LAMSs) using suitable power levels in electrosurgical workstations can increase the surgical success rate and reduce trauma. Therefore, we proposed the use of the ECE-LAMSs and electrosurgical workstations for the first time through ex vivo experiments to adjust the different power levels and select the most suitable electrosurgical power for each ECE-LAMS type.

Methods

We compared three types of ECE-LAMS (9Fr, 10.5Fr, and 10.8Fr) with three types of electrosurgical workstations during EUS-GBD. GBD was simulated ex vivo under the guidance of an ultrasound endoscope. We performed various power tests to elucidate the ideal electric power for different ECE-LAMS combined with the different types of electrosurgical workstations.

Results

For the 10.8Fr ECE-LAMS matched with the Martin, Erbe, and Olympus electrosurgical workstations, the ideal power levels were 200 W, 200 W, and 250W. For the 10.5Fr and 9Fr ECE-LAMS matched with the Martin, Erbe, and Olympus electrosurgical workstations, the ideal power levels were 150 W, 200 W, and 200 W.

Conclusion

During the operations, due to low-power levels in the electrosurgical workstations increased the number of cuts, the EUS images were obviously unclear, which affected the success rates of the operations. We suggested different power levels for the different types of LAMS and their matching electrosurgical workstations, which can increase the surgical success rates and reduce surgical injuries.

Efficacy and safety of conversion of percutaneous cholecystostomy to endoscopic transpapillary gallbladder stenting in high-risk surgical patients

BACKGROUND

Endoscopic transpapillary gallbladder stenting (ETGBS) has been used as an alternative to percutaneous cholecystostomy in patients with acute cholecystitis who are considered unfit for surgery. However, there are few data on the efficacy and safety of ETGBS replacement of percutaneous cholecystostomy in high-risk surgical patients. This study aimed to evaluate the feasibility, efficacy, and safety of ETGBS to replace percutaneous cholecystostomy in high-risk surgical patients.

METHODS

This single center retrospective study reviewed the data of patients who attempted ETGBS to replace percutaneous cholecystostomy between January 2017 and September 2019. The technical success, clinical success, adverse events, and stent patency were evaluated.

RESULTS

ETGBS was performed in 43 patients (24 male, mean age 80.7 ± 7.4 years) to replace percutaneous cholecystostomy due to high surgical risk. The technical success rate and clinical success rate were 97.7% (42/43) and 90.5% (38/42), respectively. Procedure-related adverse events and stent-related late adverse events occurred in 7.0% (3/43) and 11.6% (5/43), respectively. Of the patients who successfully underwent ETGBS (n = 42), only one had recurrent acute cholecystitis during follow-up. The median stent patency was 415 days (interquartile range 240-528 days).

CONCLUSIONS

ETGBS, as a secondary intervention for the purpose of internalizing gallbladder drainage in patients following placement of a percutaneous cholecystostomy, is safe, effective, and technically feasible. Thus, conversion of percutaneous cholecystostomy to ETGBS may be considered as a viable option in high-risk surgical patients.

Endoscopic Ultrasound-Guided Gallbladder Drainage

The mainstay of management of acute cholecystitis is surgical. Despite the advances in anesthesia and laparoscopic surgery, there is a significant pool of patients that are not candidates for surgery given their significant comorbidities and limited functional reserve. Historically percutaneous gallbladder drainage has been utilized to temporize these patients. Recently, endoscopic approaches are being explored with transpapillary and transmural drainage. In this article, we discuss the background, current status, technical challenges, adverse events, and outcomes of endoscopic ultrasound-guided gallbladder drainage for management of acute cholecystitis.

Conversion of percutaneous transhepatic biliary drainage to endoscopic ultrasound-guided biliary drainage

INTRODUCTION

Percutaneous transhepatic biliary drainage (PTBD) is a useful alternative treatment for malignant biliary obstruction (MBO) when patients have difficulty with endoscopic transpapillary drainage. We examined the feasibility of conversion of PTBD to endoscopic ultrasound-guided biliary drainage (EUS-BD) in patients with MBO unsuited for endoscopic transpapillary biliary drainage.

METHODS

This retrospective study included patients who underwent conversion of PTBD to EUS-BD between March 2017 and December 2019. Eligible patients had unresectable MBO, required palliative biliary drainage, and were not suited for endoscopic transpapillary drainage. Initial PTBD had been performed for acute cholangitis or obstructive jaundice in all patients. EUS-BD was performed following improvements in cholangitis. Sixteen patients underwent conversion of PTBD to EUS-BD. We evaluated technical success, procedure time, clinical success (defined as subsequent external catheter removal), adverse events (AEs), time to recurrent biliary obstruction (TRBO), and re-intervention rates.

RESULTS

Technical success was achieved in all patients (100%). The median procedure time was 45.0 minutes (interquartile range [IQR] 30.0-50.0 minutes). Clinical success was achieved in all patients (100%). There were mild early AEs in two patients (12.5%) (acute cholangitis: 1, bile peritonitis: 1), which improved with antibiotic administration alone. Recurrent biliary obstruction (RBO) occurred in six patients (37.5%). Kaplan-Meier analysis revealed a 50% TRBO of 95 days (IQR 41-246 days). Endoscopic treatment was possible in all RBO cases, and repeat PTBD was not required.

CONCLUSIONS

Conversion of PTBD to EUS-BD for the management of MBO is both feasible and safe. This approach is expected to be widely practiced at centers with little experience in EUS-BD.

Treatment of acute cholecystitis in high-risk surgical patients. Systematic review of the literature according to the levels of evidence

Acute cholecystitis (AC) is the most common biliary stone disease complication. While there is consensus regarding cholecystectomy for AC, gallbladder drainage is indicated in elderly or high-risk surgical patients. We systematically reviewed available evidence in the field of EUS-guided gallbladder drainage (EUS-GBD) for AC in high-risk surgical patients. The studies were classified according to their level of evidence (LE) according to the Oxford Centre for Evidence Based Medicine classification. Literature search retrieved 175 manuscripts; most of them were expert opinions (LE V, no. 53) or caseseries (LE IV, no. 29). There was no meta-analysis of RCT (LE Ia), while two randomized controlled trials (LE Ib) demonstrated that EUS-GBD was superior to percutaneous trans-hepatic-GBD (PT-GBD) regarding longterm outcomes (adverse events, recurrent cholecystitis, and reintervention). Several meta-analyses of cohort studies (LE IIa, no. 11) were designed to compare the three available drainage strategies (endoscopic, echoendoscopic and percutaneous) and to assess the pooled risk of adverse events. Comparison between surgery and EUS-GBD was done in a single retrospective study with a propensity score analysis (LE III). The outcomes of conversion from PT-GBD to EUS-GBD were covered by few retrospective studies (LE III). Several manuscripts (no. 69) were published on EUS-GBD as a rescue strategy in case of malignant biliary obstruction. The levels of evidence of EUS-GBD in the literature have evolved from initial descriptive studies to recent randomized controlled trials and meta-analysis of cohort studies. While several articles addressed the comparison among different techniques for GBD, in our opinion some topics and questions have not been adequately investigated. are still debated.

EUS guided gallbladder drainage

Cholecystectomy is the gold standard treatment for acute cholecystitis, but it may not be appropriate for patients with significant comorbidities. Percutaneous gallbladder drainage (PT-GBD) and endoscopic transpapillary gallbladder drainage (ET-GBD) are alternatives with good technical and clinical success rates, but are limited by technical challenges and the need for definitive therapy. EUS-guided gallbladder drainage (EUS-GBD) is quickly becoming the preferred modality of treatment at expert centers in this cohort of patients due to increased efficacy and minimal adverse events. Technicalities of the procedure, including selection of access site, should be informed by the ultimate needs and anatomy of each patient. With the evolution of new stents and accessories, including a cautery-enhanced lumen apposing metal stent deployment system, success rates and adverse events are favorable. A review of published case series demonstrates an overall clinical success rate of approximately 97% for EUS-GBD. The most common complication is pneumoperitoneum, so the evolution of self-expanding LAMS is promising. EUS-GBD has been successfully described in cases where definitive therapy or a bridge to cholecystectomy is needed. As the procedure's applications continue to evolve, there should be greater discussion about specific details including access site and stent selection.

Endoscopic Ultrasound-Guided Gallbladder Drainage: Current Perspectives

According to the recently updated Tokyo Guidelines, laparoscopic cholecystectomy still represents the gold standard for the treatment of acute cholecystitis. However, fragile patients, due to comorbidities or poor clinical conditions, have a high surgical risk. In such cases, percutaneous or endoscopic gallbladder drainage is considered the treatment of choice. In particular, endoscopic ultrasound-guided gallbladder drainage with the placement of specifically designed stents is now considered an alternative option. In addition, the opening of an access door to the lumen of the gallbladder could offer new opportunities for the endoscopic treatment of gallbladder diseases. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the endoscopic ultrasound-guided gallbladder drainage.

Efficacy and safety of endoscopic laser lithotripsy and lithotomy through the lumen-apposing metal stent for giant gallbladder stones

Background and Aims

EUS-guided gallbladder drainage has been increasingly applied for acute cholecystitis in high-risk surgical patients. In cases of EUS-guided gallbladder drainage with lumen-apposing metal stents (LAMSs), endoscopic retrieval of gallstones becomes feasible. However, retrieval of giant gallstones is still difficult because of the limited space in the saddle section of the LAMS. In this study, we aimed to evaluate the efficacy and safety of endoscopic laser lithotripsy and lithotomy through LAMSs for the removal of giant gallstones.

Methods

Five consecutive patients with recurrent cholecystitis due to giant gallstones were enrolled. We proceeded with EUS-guided LAMS implantation. Endoscopic laser lithotripsy and lithotomy then was performed through the LAMSs, and the stents were removed after all stones were extracted. The patients were followed up at scheduled times.

Results

EUS-guided LAMS implantation was successfully performed, and target gallstones were completely removed in all 5 patients. There was no severe bleeding, perforation, or stent migration during the operation. No recurrence of gallstones was found at late follow-up.

Conclusions

Endoscopic laser lithotripsy and lithotomy through LAMSs could be a safe and effective approach for removal of giant gallstones.

Radiologic Assessment for Endoscopic US-guided Biliary Drainage

Endoscopic US-guided biliary drainage (BD) is performed for various types of biliary obstruction and is mainly indicated for unsuccessful conventional transpapillary endoscopic retrograde cholangiodrainage. In endoscopic US BD, an extra-anatomic drainage route between the gastrointestinal (GI) tract and the biliary system is created with a covered metallic stent or plastic stent. Procedural types of endoscopic US BD include hepaticogastrostomy, hepaticojejunostomy (after gastrectomy), choledochoduodenostomy, hepaticoduodenostomy, and endoscopic US-guided gallbladder drainage. The technical and clinical success rates of endoscopic US BD are reported to be 94%-97% and 88%-100%, respectively. CT is crucial both in preprocedural assessment and postprocedural monitoring. CT is used to determine the indications for endoscopic US BD, which include the type of biliary obstruction, collateral vessels in the puncture route, ascites, the volume of the liver segment, the distribution of an intrahepatic tumor, and GI tract patency. After endoscopic US BD, common subclinical findings are a small amount of intraperitoneal gas, localized edematous change in the GI tract, a notch in the placed stent, and localized biliary dilatation caused by stent placement. Stent malfunction after endoscopic US BD is caused by impaction of debris and/or food, stent migration into the GI tract, or tumor overgrowth and/or hyperplasia. Complications that can occur include internal stent migration, intraperitoneal biloma, arterial bleeding or pseudoaneurysm, perforation of the GI tract, and portobiliary fistula. The incidence of clinical endoscopic US BD-related complications is 11%-23%. ^©RSNA, 2020.

Tips for Dealing with Common Beginner's Mistakes Made during Endoscopic Ultrasound-Guided Gallbladder Drainage

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been performed as an alternative to percutaneous drainage in surgically high-risk patients. Technical failures of EUS-GBD made by beginners are often attributed to failure of over-the-wire insertion of a fistula-dilating device or stent delivery system into the gallbladder, or stent misplacement in the final technical step. We herein report technical tips to prevent the failure of fistula dilation and provide tricks to avoid inward or outward stent misplacement.

EUS-guided gallbladder drainage: a learning curve modified by technical progress

Introduction  Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an efficacious and safe option for patients who cannot undergo cholecystectomy. It is a technically challenging procedure, requiring skills in EUS, and ERCP. The aim of this study was to define the learning curve for EUS-GBD. Patients and methods  Consecutive patients undergoing EUS-GBD by a single operator were included from a prospective registry over 5 years. Demographics, procedure information, post-procedure follow-up data, and information on adverse events were collected. Non-linear regression and CUSUM analyses were conducted for the learning curve. Clinical success was defined as resolution of cholecystitis post-procedure. Results  Forty-eight patients were included (58 % male, mean age 76 years). Twenty patients (42 %) had malignant cholecystitis. Most patients had lumen-apposing metal stents (LAMS) (15 mm, n = 29, 60 %; 10 mm, n = 8, 7 %). The remaining patients had FCSEMS (n = 9, 19 %) or plastic stents alone (n = 2, 4 %). Clinical success was achieved in 36 (86 %) of patients. Of the remaining 12, 7 were lost to follow-up and 5 had persistent cholecystitis. 9 patients (19 %) had adverse events including bleeding (n = 4), liver abscesses (n = 2), and hypotension. Two patients passed away post-procedure. Median procedure time was 41 minutes (range 16 - 121 min), with the 41-minute time occurring during the 19th procedure. Procedure durations further reduced, with the last 10 procedures being 20 minutes or under (nonlinear regression p value P  < 0.0001). Conclusion  Endoscopists experienced in EUS-GBD are expected to achieve a reduction in procedure time over successive cases, with efficiency reached at 41 minutes and a learning rate of 19 cases. Continued improvement is demonstrated with additional experience.

Technical issues stemming from endoscopic-ultrasound-guided gallbladder drainage: A single center experience

BACKGROUND/AIMS

This study was conducted to evaluate the outcomes of endoscopic-ultrasound-guided gallbladder drainage (EUS-GBD) using traditional biliary stents without lumen-apposing stents and to determine technical issues.

MATERIALS AND METHODS

All 18 patients who underwent EUS-GBD at our center between 2012 and 2018 were evaluated. After the clinical outcomes (including technical success, clinical effectiveness, adverse events, and recurrence) were analyzed, technical countermeasures for problems extracted from the analysis were developed.

RESULTS

The rates of technical success, clinical effectiveness, severe adverse event occurrence, and recurrence of acute cholecystitis were 94% (17/18), 88% (15/17), 6% (1/18, massive bile leakage), and 27% (4/15), respectively. Distal gastrectomy causing scope instability, the non-swollen gallbladder, and double pigtail stent use caused technical difficulties. A fully covered metal stent (fcMS) should be placed in a shallow position so that it does not wedge into the opposite site. When the puncture route involves the gastric wall, the proximal portion of an fcMS located in the stomach can migrate toward the abdominal cavity.

CONCLUSION

Although the clinical outcomes of EUS-GBD were relatively favorable, several technical issues related specifically to EUS-GBD were observed. Technical countermeasures would improve the outcomes.

Therapeutic EUS: New tools, new devices, new applications

Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.

Endoscopic ultrasound guided gallbladder drainage - is it ready for prime time?

Management of acute cholecystitis includes initial stabilization and antibiotics. However, the most definitive treatment is cholecystectomy. A small percentage of patients who are not suitable for surgery due to the severity of cholecystitis or comorbidities will require a temporary measure as a bridge to surgery or permanent nonoperative management to decrease the mortality and morbidity. Most of these patients who require conservative management were managed with percutaneous transhepatic cholecystostomy or trans-papillary drainage of gallbladder drainage with cystic duct stenting through endoscopic retrograde cholangiopancreaticography (ERCP). Although, these conservative measures are effective, they can cause significant discomfort to the patients especially if used as a long-term measure. In view of this, there is a need for further minimally invasive procedures, which is safe, effective and comfortable to patients. Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel method of gallbladder drainage first described in 2007^[1]. Over the last decade, EUS guided gallbladder drainage has evolved as an effective alternative to percutaneous cholecystostomy and trans-papillary gallbladder drainage. Our goal is to review available literature regarding the scope of EUS guided gallbladder drainage as a viable alternative to percutaneous cholecystostomy or cystic duct stenting through ERCP among patients who are not suitable for cholecystectomy.