Endoscopic ultrasound-assisted transmural cholecystoduodenostomy or cholecystogastrostomy as a bridge for per-oral cholecystoscopy therapy using double-flanged fully covered metal stent

A review of endoscopic ultrasound-guided gallbladder drainage and gastroenterostomy: assisted approaches and comparison with alternative techniques

Over the last 40 years, the role of endoscopic ultrasound (EUS) has evolved from being diagnostic to therapeutic. EUS-guided gallbladder drainage (EUS-GBD) and EUS-guided gastroenterostomy (EUS-GE) are emerging techniques in recent years; however, there are limited studies and inconsistent results regarding these techniques. In addition, EUS has become a more common alternative to traditional interventions due to its super minimally invasive nature, but the mobility of both the gallbladder and intestine makes it challenging to introduce stents. An increasing number of researchers are dedicating themselves to solving this problem, leading to the development of various assisted technologies. Consequently, this review focused on the comparison of EUS-GBD and EUS-GE with other alternative approaches and explored the various assisted techniques employed for EUS-GBD and EUS-GE.

Endoscopic Management of Benign Gallbladder Diseases

Acute cholecystitis, cholelithiasis, and gallbladder polyps represent the most gallbladder benign diseases. Endoscopic approaches for the management of these diseases were an alternative to standard laparoscopic cholecystectomy. These endoscopic approaches include transpapillary approaches via endoscopic retrograde cholangiopancreatography, transmural access approaches via endoscopic ultrasound, and endoscopic surgical approaches using natural orifice transluminal endoscopic surgery approaches. However, it's still uncertain which approach is associated with the superior clinical outcomes due to the lack of high-level evidence. Our review provides new insight into the endoscopic approaches for the management of gallbladder benign diseases, with the latest evidence included.

Current considerations for the surgical management of gallbladder adenomas

Gallbladder adenomas are rare lesions (0.5%) associated with potential malignant transformation, particularly with gallbladder adenomas that are ≥ 1 cm in size. Early detection and management are crucial for preventing lethal carcinoma development. These polyps can often be distinguished from the more often nonneoplastic cholesterol pseudopolyps (5%-10%), which are benign. Ultrasonography is the first-line tool for initial diagnosis and follow-up when indicated. The question is whether cholecystectomy is always necessary for all adenomas. The management of gallbladder adenomas is determined according to the size of the tumor, the growth rate of the tumor, the patient's symptoms and whether risk factors for malignancy are present. Adenomas ≥ 1 cm in size, an age > 50 years and a familial history of gallbladder carcinoma are indications for immediate laparoscopic cholecystectomy. Otherwise, ultrasound follow-up is indicated. For adenomas 6-9 mm in size, the absence of ≥ 2 mm growth at 6 months, one year, and two years, as well as an adenoma sized < 5 mm without existing risk factors indicates that no further surveillance is required. However, it would be preferable to individualize the management in doubtful cases. Novel interventional modalities for preserving the gallbladder need further evaluation, especially to determine the long-term outcomes.

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.

EUS-Guided Cholecystoduodenostomy for a Poor Surgical Candidate With Chronic Octreotide-Associated Gallstones From Metastatic Neuroendocrine Tumor

Chronic octreotide use has been associated with gallstone formation. Historically, cholecystectomy has been the defining treatment for those who have gallstone-related disease. For those who are poor surgical candidates, percutaneous and endoscopic approaches have been used. We describe the endoscopic management of a 74-year-old man with significant gallstone burden and associated sequelae because of chronic octreotide for metastatic neuroendocrine tumor through endoscopic ultrasound-guided cholecystoduodenostomy with gallstone extraction using lumen-apposing metal stents.

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.

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.

Peroral cholecystoscopy using a multibending ultraslim endoscope through a lumen-apposing metal stent for endoscopic ultrasound-guided gallbladder drainage: a feasibility study

BACKGROUND

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) has rendered endoscopic gallbladder assessment through a stent possible, but an appropriate endoscope is required. We assessed the feasibility of peroral cholecystoscopy (POCC) using a multibending ultraslim endoscope passed through a LAMS after EUS-GBD.

METHODS

14 patients with a LAMS for EUS-GBD who consecutively underwent POCC were included. POCC was performed using a multibending endoscope inserted through the LAMS. The primary outcome was the technical success rate, defined as complete endoscopic examination of the gallbladder from the orifice of the cystic duct to the fundus. The types of intervention and adverse events were recorded.

RESULTS

17 POCCs were performed in 14 patients. Of the 17 POCCs, 15 (88.2 %) were technically successful. Narrow-band imaging endoscopy was performed in 12 procedures (70.6 %), and cholecystoscopy-guided target biopsies were obtained in six. Gallstone extraction was performed in two patients. After POCC, all LAMSs remained stable and no adverse events were observed.

CONCLUSIONS

POCC using a multibending ultraslim endoscope can be effectively and safely performed through a LAMS after EUS-GBD.

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

1:  ESGE recommends a prolonged course of a prophylactic broad-spectrum antibiotic in patients with ascites who are undergoing therapeutic endoscopic ultrasound (EUS) procedures.Strong recommendation, low quality evidence. 2:  ESGE recommends placement of partially or fully covered self-expandable metal stents during EUS-guided hepaticogastrostomy for biliary drainage in malignant disease.Strong recommendation, moderate quality evidence. 3:  ESGE recommends EUS-guided pancreatic duct (PD) drainage should only be performed in high volume expert centers, owing to the complexity of this technique and the high risk of adverse events.Strong recommendation, low quality evidence. 4:  ESGE recommends a stepwise approach to EUS-guided PD drainage in patients with favorable anatomy, starting with rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP), followed by antegrade or transmural drainage only when RV-ERP fails or is not feasible.Strong recommendation, low quality evidence. 5:  ESGE suggests performing transduodenal EUS-guided gallbladder drainage with a lumen-apposing metal stent (LAMS), rather than using the transgastric route, as this may reduce the risk of stent dysfunction.Weak recommendation, low quality evidence. 6:  ESGE recommends using saline instillation for small-bowel distension during EUS-guided gastroenterostomy.Strong recommendation, low quality evidence. 7:  ESGE recommends the use of saline instillation with a 19G needle and an electrocautery-enhanced LAMS for EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) procedures.Strong recommendation, low quality evidence. 8:  ESGE recommends the use of either 15- or 20-mm LAMSs for EDGE, with a preference for 20-mm LAMSs when considering a same-session ERCP.Strong recommendation, low quality evidence.

EUS-guided gallbladder drainage and subsequent peroral endoscopic cholecystolithotomy: A tool to reduce chemotherapy discontinuation in neoplastic patients?

BACKGROUND AND AIMS

EUS-guided gallbladder drainage (EUS-GBD) is emerging as a valuable treatment for acute cholecystitis (AC) in patients unfit for surgery. When lumen-apposing metal stents are used, large-caliber access to the gallbladder allows for subsequent direct peroral endoscopic cholecystoscopy (POEC) and eventual cholecystolithotomy (CL), offering a potentially "curative" solution for frailer patients. The aim of this series was to evaluate the outcome of these procedures in oncologic patients experiencing AC, with a specific focus on chemotherapy continuity.

METHODS

A prospective registry of all consecutive therapeutic EUS procedures performed in the San Raffaele Institute between December 2020 and April 2021 was searched for EUS-GBD + POEC-CL performed in chemotherapy candidates. Clinical and technical variables were prospectively registered, as were days of chemotherapy delay and postprocedural outcomes.

RESULTS

Three consecutive patients with a diagnosis of a malignancy (2 pancreatic cancers and 1 severe myeloproliferative disease with skeletal lesions) experienced AC and were primarily treated by EUS-GBD. After 4 weeks, they were systematically scheduled for POEC-CL and lumen-apposing metal stent exchange for a double-pigtail plastic stent. All procedures and revisions were successful, with rapid clinical improvement. All gallbladders were cleared of food debris and stones between 3 and 15 mm using grasping forceps, polypectomy snares, Dormia baskets, and mechanical lithotripsy. One mild adverse event without any clinical consequence was registered during POEC-CL. Revisions did not interfere with the chemotherapy schedule. Technical variables (eg, gastric vs duodenal drainage or need for coaxial double-pigtail plastic stent) are discussed.

CONCLUSIONS

EUS-GBD and subsequent POEC-CL allows a highly effective and minimally invasive solution for AC. These initial experiences promote further evaluation of this approach for all those individuals in whom surgical interventions are undesirable, such as oncologic patients whose prognosis depends on chemotherapy continuity, although further prospective confirmation in this setting should be pursued.

Endoscopic gallbladder drainage for symptomatic gallbladder disease: a cumulative systematic review meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided transmural or endoscopic retrograde cholangiography (ERC)-based transpapillary drainage may provide alternative treatment strategies for high-risk surgical candidates with symptomatic gallbladder (GB) disease. The primary aim of this study was to perform a systematic review and meta-analysis to investigate the efficacy and safety of endoscopic GB drainage for patients with symptomatic GB disease.

METHODS

Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed in accordance with PRISMA and MOOSE guidelines. Pooled proportions were calculated for measured outcomes including technical success, clinical success, adverse event rate, recurrence rate, and rate of reintervention. Subgroup analyses were performed for transmural versus transpapillary, transmural lumen apposing stent (LAMS), and comparison to percutaneous transhepatic drainage. Heterogeneity was assessed with I² statistics. Publication bias was ascertained by funnel plot and Egger regression testing.

RESULTS

Thirty-six studies (n = 1538) were included. Overall, endoscopic GB drainage achieved a technical and clinical success of 87.33% [(95% CI 84.42-89.77); I² = 39.55] and 84.16% [(95% CI 80.30-87.38); I² = 52.61], with an adverse event rate of 11.00% [(95% CI 9.25-13.03); I² = 7.08]. On subgroup analyses, EUS-guided transmural compared to ERC-assisted transpapillary drainage resulted in higher technical and clinical success rates [OR 3.91 (95% CI 1.52-10.09); P = 0.005 and OR 4.59 (95% CI 1.84-11.46); P = 0.001] and lower recurrence rate [OR 0.17 (95% CI 0.06-0.52); P = 0.002]. Among EUS-guided LAMS studies, technical success was 94.65% [(95% CI 91.54-96.67); I² = 0.00], clinical success was 92.06% [(95% CI 88.65-94.51); I² = 0.00], and adverse event rate was 11.71% [(95% CI 8.92-15.23); I² = 0.00]. Compared to percutaneous drainage, EUS-guided drainage possessed a similar efficacy and safety with significantly lower rate of reintervention [OR 0.05 (95% CI 0.02-0.13); P < 0.001].

DISCUSSION

Endoscopic GB drainage is a safe and effective treatment for high-risk surgical candidates with symptomatic GB disease. EUS-guided transmural drainage is superior to transpapillary drainage and associated with a lower rate of reintervention compared to percutaneous transhepatic drainage.

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.

How to perform EUS-based cholecystolithotomy

EUS-guided gallbladder drainage (EUS-GBD) is gradually emerging as an option for patients with cholecystitis. A stent-bridged endoscopic intervention in the gallbladder (GB) has been proposed. The formation of a fistulous tract after EUS-GBD facilitates the entry of the endoscope inside the GB to perform endoscopic lithotomy and polypectomy, which is an efficient and safe procedure. However, the technical aspects of this procedure in order to optimize the success rate have only been scarcely discussed. This paper discusses the EUS-GBD prepared for per-oral cholecystolithotomy, the stent indwelling time, the procedure, the devices of per-oral cholecystolithotomy and the follow-up. The recently published literature on this topic is also updated in this review.

Current Status in the Treatment of Acute Cholecystitis Patients Receiving Antithrombotic Therapy: Is Endoscopic Drainage Feasible?- A Systematic Review

The bleeding complication risk of surgery or percutaneous transhepatic gallbladder drainage (PTGBD) may increase in patients with acute cholecystitis receiving antithrombotic therapy (ATT). Endoscopic gallbladder drainage (EGBD) may be recommended for such patients. English articles published between 1991 and 2018 in peer-reviewed journals that discuss cholecystectomy, PTGBD, and EGBD in patients with ATT or coagulopathy were reviewed to assess the safety of the procedures, especially in terms of the bleeding complication. There were 8 studies on cholecystectomy, 3 on PTGBD, and 1 on endoscopic transpapillary gallbladder drainage (ETGBD) in patients receiving ATT. With respect to EGBD, 28 studies on ETGBD (including 1 study already mentioned above) and 26 studies on endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) were also analyzed. The overall bleeding complication rate in patients with ATT who underwent cholecystectomy was significantly higher than that in patients without ATT (6.5% [23/354] vs. 1.2% [26/2,224], p<0.001). However, the bleeding risk of cholecystectomy and PTGBD in patients receiving ATT was controversial. The overall technical success, clinical success, and bleeding complication rates of ETGBD vs. EUS-GBD were 84% vs. 96% (p<0.001), 92% vs. 97% (p<0.001), and 0.65% vs. 2.1% (p=0.005), respectively. One patient treated with ETGBD experienced bleeding complication among 191 patients with bleeding tendency. ETGBD may be an ideal drainage procedure for patients receiving ATT from the viewpoint of bleeding, although EUS-GBD is also efficacious.

Outcomes of an international multicenter registry on EUS-guided gallbladder drainage in patients at high risk for cholecystectomy

Background and study aims  The aim of the current study was to review the outcomes of a large-scale international registry on endoscopic ultrasound-guided gallbladder drainage (EGBD) that encompasses different stent systems in patients who are at high-risk for cholecystectomy. Patients and methods  This was a retrospective international multicenter registry on EGBD created by 13 institutions around the world. Consecutive patients who received EGBD for several indications were included. Outcomes include technical and clinical success, unplanned procedural events (UPE), adverse events (AEs), mortality, recurrent cholecystitis and learning curve of the procedure. Results  Between June 2011 and November 2017, 379 patients were recruited to the study. Technical and clinical success were achieved in 95.3 % and 90.8 % of the patients, respectively. The 30-day AE rate was 15.3 % and 30-day mortality was 9.2 %. UPEs were significantly more common in patients with EGBD performed for conversion of cholecystostomy and symptomatic gallstones ( P  < 0.001); and by endoscopists with experience of fewer than 25 procedures ( P  = 0.033). Both presence of clinical failure ( P  = 0.014; RR 8.69 95 %CI [1.56 - 48.47]) and endoscopist experience with fewer than 25 procedures ( P  = 0.002; RR 4.68 95 %CI [1.79 - 12.26]) were significant predictors of 30-day AEs. Presence of 30-day AEs was a significant predictor of mortality ( P  < 0.001; RR 103 95 %CI [11.24 - 944.04]). Conclusion  EGBD was associated with high success rates in this large-scale study. EGBD performed for indications other than acute cholecystitis was associated with higher UPEs. The number of cases required to gain competency with the technique by experienced interventional endosonographers was 25 procedures.

Efficacy and Safety of Lumen Apposing Self-Expandable Metal Stents for EUS Guided Cholecystostomy: A Meta-Analysis and Systematic Review

BACKGROUND

Patients with acute cholecystitis are treated with early cholecystectomy. A subset of patients are unfit for surgery due to comorbidities and late presentation. Prompt gall bladder drainage (GBD) with percutaneous or endoscopic approach remains a viable therapeutic option for nonoperative candidates. Endoscopic ultrasound (EUS) guided transluminal gall bladder drainage (EUS-GBD) continues to evolve as an alternative approach to percutaneous drainage. With continued refinement in stent technology, lumen apposing self-expandable metal stent (LAMS) offers several advantages. We performed a pooled analysis on the efficacy and safety of EUS-GBD with LAMS in nonoperative candidates with acute cholecystitis.

METHODS

Extensive English language literature search was performed in Medline, Embase, Cochrane Central, and Google Scholar using keywords "endoscopic ultrasound", "stent", "gallbladder", "acute cholecystitis", and "cholecystostomy" from Jan 2000 to Dec 2016. Fixed and random effects models were used to calculate the pooled proportions.

RESULTS

Data was extracted from 13 studies that met the inclusion criteria (n = 233). Pooled proportion of technical success was 93.86% (95% CI = 90.56 to 96.49) and clinical success was 92.48% (95% CI = 88.9 to 95.42). Overall complication rate was 18.31% (95% CI = 13.49 to 23.68) and stent related complication rate was 8.16% (95% CI = 4.03 to 14.96) in the pooled percentage of patients. Pooled proportion for perforation was 6.71% (95% CI 3.65 to 10.6) and recurrent cholangitis/cholecystitis was noted in 4.05% (95% CI = 1.64 to 7.48). Publication bias calculated using Harbord-Egger bias indicator gave a value of -0.61 (95%  CI = -1.39 to 0.16, p = 0.11). The Begg-Mazumdar indicator for bias gave Kendall's tau b value of -0.42 (p ≥ 0.05).

CONCLUSIONS

EUS-GBD with LAMS is a safe and alternative treatment modality for patients needing gallbladder drainage, with acceptable intraprocedural and postprocedural complications. However, due to the limited data and lack of direct comparison with other methods, further controlled trials are necessary to estimate the overall efficacy and safety and the role of EUS-GBD with LAMS in management of nonoperative patients with acute cholecystitis.

Endoscopic Ultrasound-Guided Gallbladder Drainage

Recent literature has demonstrated effectiveness and safety of endoscopic ultrasound-guided gallbladder drainage, both as a primary intervention in patients with cholecystitis who are unfit for urgent surgical intervention and as a secondary intervention to internalize biliary drainage after initial placement of a percutaneous cholecystostomy catheter.

EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device

BACKGROUND AND AIMS

In high-risk surgical patients, the treatment of choice of acute cholecystitis is percutaneous transhepatic gallbladder drainage (PTGBD). Recently, a novel endoscopic device containing a lumen-apposing metal stent with an electrocautery (ECE-LAMS) on the tip has been developed.

METHODS

High-risk surgical patients with acute cholecystitis who underwent EUS-guided gallbladder drainage (EUS-GBD) with the novel device were retrospectively retrieved from 7 tertiary care referral centers. Main endpoints were technical and clinical success rates, rate of procedural adverse events, and short- and long-term adverse events.

RESULTS

Seventy-five patients (mean age, 75 ± 11 years; 36 men) underwent EUS-GBD. The procedure was technically and clinically successful in 98.7% and 95.9% of cases, respectively. Three patients without resolution of cholecystitis died, and 2 patients had procedure-related adverse events: 1 perforation requiring surgery and 1 major bleeding resolved conservatively. The mean follow-up for the entire cohort was 201 ± 226 days. Seven patients (9.6%) died within the first 30 days; 50 patients (71.4%) were alive at the last date of follow-up. Short- and long-term adverse events occurred in 6 patients: 3 had recurrent cholecystitis, 2 had migration of the stent, and 1 developed Bouveret syndrome, all managed nonsurgically. Overall, 8 adverse events (10.7%) occurred in the entire cohort of patients.

CONCLUSIONS

The novel ECE-LAMS for high-risk surgical patients with acute cholecystitis is safe, with a high technical and clinical success rate. Future multicenter studies comparing EUS-GBD versus PTGBD are warranted to determine which procedure is safer and clinically more effective for patients with high surgical risk acute cholecystitis.

Current status of interventional endoscopic ultrasound

Endoscopic ultrasound (EUS) is being used increasingly in the management of pancreatic fluid collection, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of the gallbladder, and other conditions. The role of interventional EUS is rapidly expanding and new interventions are continuously emerging. The development of devices could be a major breakthrough in the field of interventional EUS. New devices would enable the expansion of its role even further and prompt its widespread use in clinical practice. This review focuses on the current status of interventional EUS, especially highlighting the topics that are presently drawing the interest of endoscopists.