Endoscopic ultrasound-assisted cholecystogastrostomy by a novel fully covered metal stent for the treatment of gallbladder stones

Endoscopic ultrasound-guided gallbladder endoscopic mucosal resection: a pilot porcine study

INTRODUCTION

Endoscopic ultrasound (EUS)-guided natural orifice transluminal gallbladder polypectomy provides a minimally invasive alternative to cholecystectomy. The study aimed to investigate the feasibility and safety of protocol for gallbladder endoscopic mucosal resection (gEMR) under EUS guidance using a porcine model.

MATERIAL AND METHODS

Fifteen Bama mini pigs were randomly divided into the control (CG, n = 3) and experimental (EG, n = 12) groups. EUS-guided fine needle aspiration was performed in the CG and used to establish a gallbladder pathway for polyp resection under EUS guidance in the EG. Procedural safety was evaluated using routine blood and biochemical tests, microbial bile cultures, histopathological tests, and enzyme-linked immunosorbent assays for inflammatory adhesion factors.

RESULTS

EUS-guided metal stents were successfully deployed in all 12 pigs. Two cases of stent displacement occurred postoperatively, and one pig died of infectious peritonitis on the first day after stent implantation. In 11 surviving experimental animals, mature gallbladder paths were formed at 7-14 days after gastro-cholecystostomy, through which gEMR of gallbladder polyps was successfully performed. There were no significant changes in levels of inflammatory and adhesion factors during the postoperative process.

CONCLUSIONS

EUS-gEMR may be a safe and effective minimally invasive treatment approach for gallbladder polyps.

The clinical effect of a strategy called transcystic gallbladder-preserving cholecystolithotomy based on endoscopic retrograde cholangiopancreatography for cholecystolithiasis: A retrospective study from a single center

Background

Choledocholithiasis complicated with cholecystolithiasis is a common disease. This study explores a novel strategy, called ERCP-based transcystic gallbladder-preserving cholecystolithotomy, for the simultaneous removal of common bile duct stones and gallbladder stones.

Methods

From December 2018 to June 2021, all patients with cholecystolithiasis and common bile duct stones who met the criteria for gallbladder preservation in our hospital were included in the study and prospectively followed up.

Results

We included 48 patients, including 20 patients with acute biliary pancreatitis. All patients successfully underwent ERCP to remove common bile duct stones. One patient had gallbladder perforation during gallbladder-preserving cholecystolithotomy. The guide wire successfully entered the gallbladder, and the transpapillary gallbladder metal-covered stent was successfully placed in 44 patients. The technical success rate was 91.67% (44/48). All stones were removed in 34 patients, for a clinical success rate of 77.27% (34/44). The total postoperative complication rate was 6.25% (3/48), with 2 cases of pancreatitis (4.17%) and 1 case of cholangitis (2.08%). Three patients were lost to follow-up. Among the 31 patients who were followed up for a mean of 27 months (6-40), 5 patients (16.13%) experienced gallstone recurrence. The recurrence rates at 12 months, 18 months, 24 months, 30 months and 36 months were 0%, 3.23%, 6.45%, 12.9%, and 16.13%, respectively.

Conclusion

For patients with cholecystolithiasis and common bile duct stones, ERCP-based transcystic gallbladder-preserving cholecystolithotomy without gallbladder incision can preserve gallbladder structure, and this procedure is safe and feasible for the protection of gallbladder function.Clinical trial registration: The study was registered in the Chinese Clinical Trial Registry, and the registry number is ChiCTR1900028006.

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.

Fairchild AH, Hohenwalter EJ, Gipson MG, Al-Refaie WB, Braun AR, Cash BD, Kim CY, Pinchot JW, Scheidt MJ, Schramm K, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria® Radiologic Management of Biliary Obstruction

Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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.

Endoscopic transpapillary stenting for the management of acute cholecystitis

INTRODUCTION

Cholecystectomy is the gold standard treatment of acute cholecystitis. Patients who are considered not to be candidates for cholecystectomy are commonly recommended to undergo percutaneous transhepatic gallbladder drainage (PTGBD) tube placement; however, external drainage is undesirable for many patients. Endoscopic transpapillary stent placement (ETSP) has been described as an alternative method for decompression of the gallbladder. Data in support of this technique is limited to a handful of observational studies with variable indications. Our study sought to expand on the available data for the use of ETSP exclusively in the context of acute cholecystitis.

METHODS

We performed a retrospective chart review of patients with cholecystitis who underwent ETSP at our institution between January 2012 and July 2018. We collected data on indication, comorbidities, length of stay, laboratory values, outcomes, additional procedures, and whether cholecystectomy was eventually performed.

RESULTS

During the study period, 12 patients underwent ETSP. The mean age was 68.2 years (± SD 12.4) with an average Anesthesia Society Assessment (ASA) class of 3.2. The Charlson Comorbidity Index was greater than seven in 75% of patients, indicating a 0% estimated 10-year survival. The National Surgical Quality Improvement Program (NSQIP) surgical risk calculator was used to estimate an average mortality risk for laparoscopic cholecystectomy of 4.8% (± 3.3, 95% CI) in our study population; the estimated risk in the general population is 0.1%. Immediate resolution of symptoms with endoscopic drainage was achieved in 11 of 12 patients (91.7%); one patient experienced no symptom resolution with endoscopic drainage nor subsequent PTGBD tube placement. Six of 12 (50%) patients experienced recurrence of symptoms requiring hospitalization, and two of 12 patients (16.7%) died secondary to biliary sepsis.

CONCLUSION

Endoscopic transpapillary stent placement is an alternative method for the management of acute cholecystitis patients who are not candidates for surgery. ETSP has a high technical success rate; however, it may result in a high rate of symptom recurrence and should only be utilized in select patients. Randomized studies would be beneficial to further investigate the utility and safety of ETSP in the management of acute cholecystitis.

Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage with Lumen-apposing Metal Stents or Plastic Double-pigtail Stents: A Multifactorial Analysis

Objective

To compare the efficiency of plastic and metal stents for symptomatic pancreatic pseudocyst (PP) drainage and analyze other main associated factors that affect the outcome of drainage therapy.

Method

Rates of technical and clinical success, procedure-related side effects (hemorrhage, stent migration, and cyst rupture), reinterventions, and duration of hospital stay.

Results

There were 52 patients, 40 patients underwent plastic stent placement and 12 patients underwent lumen-apposing metal stent (LAMS) placement. The total rate of technical success was 100%. The total rate of clinical success was 100%. The total rate of adverse events was 7.7% (4/52). On multiple logistic regression analysis, the use of plastic stents (P < 0.05, Exp B = 12.168) and the presence of a large cyst (P < 0.05, Exp B = 1.036) were shown to significantly increase the risk of reintervention. On multivariate linear regression analysis, etiology of pseudocyst (P < 0.05, B = -8.427, -9.785, -5.514) was associated with prolonged hospital stent, while stent type was not shown be a factor (P > 0.05).

Conclusion

Both plastic and LAMSs are proven to be highly efficient in PP drainage. The LAMS is superior in preventing complications such as migration and cyst leakage and reducing the rate of reintervention.

Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage with Lumen-apposing Metal Stents or Plastic Double-pigtail Stents: A Multifactorial Analysis

OBJECTIVE

To compare the efficiency of plastic and metal stents for symptomatic pancreatic pseudocyst (PP) drainage and analyze other main associated factors that affect the outcome of drainage therapy.

METHOD

Rates of technical and clinical success, procedure-related side effects (hemorrhage, stent migration, and cyst rupture), reinterventions, and duration of hospital stay.

RESULTS

There were 52 patients, 40 patients underwent plastic stent placement and 12 patients underwent lumen-apposing metal stent (LAMS) placement. The total rate of technical success was 100%. The total rate of clinical success was 100%. The total rate of adverse events was 7.7% (4/52). On multiple logistic regression analysis, the use of plastic stents (P < 0.05, Exp B = 12.168) and the presence of a large cyst (P < 0.05, Exp B = 1.036) were shown to significantly increase the risk of reintervention. On multivariate linear regression analysis, etiology of pseudocyst (P < 0.05, B = -8.427, -9.785, -5.514) was associated with prolonged hospital stent, while stent type was not shown be a factor (P > 0.05).

CONCLUSION

Both plastic and LAMSs are proven to be highly efficient in PP drainage. The LAMS is superior in preventing complications such as migration and cyst leakage and reducing the rate of reintervention.

Percutaneous transhepatic versus EUS-guided gallbladder drainage for malignant cystic duct obstruction

BACKGROUND AND AIMS

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been proposed as an alternative management strategy for acute cholecystitis caused by malignant cystic duct obstruction in patients for whom surgery is not an option. This study aimed to compare the results of EUS-GBD with those of percutaneous transhepatic gallbladder drainage (PTGBD) for palliative management of malignant cystic duct obstruction with acute cholecystitis or symptomatic gallbladder hydrops.

METHODS

Between November 2013 and November 2015, 14 patients with acute cholecystitis or symptomatic gallbladder hydrops as a result of malignant cystic duct obstruction underwent EUS-GBD with covered metal stents. Nineteen patients with acute cholecystitis as a result of malignant cystic duct obstruction who received PTGBD served as a control group. Patients' medical records were reviewed retrospectively.

RESULTS

The technical and clinical success rates of EUS-GBD were 85.7% (12/14) and 91.7% (11/12) and of PTGBD were 100% (19/19) and 86.4% (17/19), respectively. The groups had similar adverse event rates (28.5% and 21.1%, respectively). The average duration of stent patency in patients with EUS-GBD was 130.3 ± 35.3 days, and no patient required an additional procedure before death. In 6 of 17 patients (35.3%) with clinically successful PTGBD, the catheter was not removed until the end stage of life.

CONCLUSIONS

EUS-GBD is a feasible, safe, and effective modality for the treatment of malignant cystic duct obstruction in patients who are not indicated for surgery. It enables improved long-term quality of life in patients with advanced-stage cancer.

Endoscopic ultrasound-guided placement of the lumen-apposing self-expandable metallic stent for gallbladder drainage: a promising technique

Acute cholecystitis and other clinical problems requiring gallbladder removal or drainage have conventionally been treated with surgery, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic drainage of the gallbladder and/or extrahepatic bile duct. Patients unable to undergo these procedures due to functional status or anatomical anomalies are candidates for endoscopic ultrasound (EUS)-guided gallbladder drainage with stent placement. The aim of this review was to evaluate the technical feasibility and efficacy of EUS-guided placement of the recently developed lumen-apposing self-expandable metallic stent (LASEMS). A literature review was performed to identify the studies describing this technique. In this review article we have summarized case series or reports describing EUS-guided LASEMS placement. The indications, techniques, limitations and complications reported are discussed. A total of 78 patients were included across all studies described thus far in the literature. Studies have reported near 100% technical and clinical success rates in selected cases. No major complications were reported. EUS-guided gallbladder drainage and LASEMS placement can be a safe and effective alternative approach in the management of selected patients.