Endoscopic ultrasound‐guided gallbladder drainage: Current status and future prospects

Early surgical treatment using the laparoscopic approach is generally accepted as the treatment of choice for acute cholecystitis (AC) according to Tokyo Guidelines 2018 (TG2018). If the patient is a poor candidate for surgery because of the presence of advanced malignancy or severe organ failure, this treatment may be too invasive. In such cases, gallbladder drainage is considered an alternative treatment method to surgery. Several drainage methods have been established, such as percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic transpapillary gallbladder drainage (ETGBD) under endoscopic retrograde cholangiopancreatography (ERCP), including endoscopic naso‐gallbladder drainage (ENGBD) and endoscopic gallbladder stenting (EGBS). PTGBD is a well‐established procedure that is relatively easily carried out by general clinicians. And ETGBD has been developed as an alternative drainage method. The procedure also calls for guidewire passage across the cystic duct. Therefore, in AC cases who are contraindicated for surgery, PTGBD should be considered before ETGBD, and ETGBD may be considered only in high‐volume institutes where expert hands are available, as described in the TG2018. However, there are several limitations to these procedures. Recently, endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) is increasingly being done as an alternative method to PTGBD and ETGBD. In this review, the current status and problems of EUS‐GBD are reviewed, including technical review and clinical data of previous papers, current indication, long‐term outcome, and comparison data with PTGBD or ETGBD, and their future prospects are discussed.     

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.     

TG13 indications and techniques for gallbladder drainage in acute cholecystitis (with videos)

Percutaneous transhepatic gallbladder drainage (PTGBD) is considered a safe alternative to early cholecystectomy, especially in surgically high-risk patients with acute cholecystitis. Although randomized prospective controlled trials are lacking, data from most retrospective studies demonstrate that PTGBD is the most common gallbladder drainage method. There are several alternatives to PTGBD. Percutaneous transhepatic gallbladder aspiration is a simple alternative drainage method with fewer complications; however, its clinical usefulness has been shown only by case-series studies. Endoscopic naso-gallbladder drainage and gallbladder stenting via a transpapillary endoscopic approach are also alternative methods in acute cholecystitis, but both of them have technical difficulties resulting in lower success rates than that of PTGBD. Recently, endoscopic ultrasonography-guided transmural gallbladder drainage has been reported as a special technique for gallbladder drainage. However, it is not yet an established technique. Therefore, it should be performed in high-volume institutes by skilled endoscopists. Further prospective evaluations of the feasibility, safety, and efficacy of these various approaches are needed. This article describes indications and techniques of drainage for acute cholecystitis. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.     

What makes acute cholecystitis recur after removing the percutaneous cholecystostomy tube?

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment option for acute cholecystitis. However, the disease may recur after PTGBD catheter removal. This study aimed to evaluate the role of endoscopic sphincterotomy and other risk factors in reducing the recurrence of cholecystitis.We retrospectively analyzed data from 1088 patients who underwent PTGBD for cholecystitis at Kyungpook National University Hospital, Republic of Korea, between January 2011 and April 2018.A total of 115 patients were enrolled in the study. The recurrence rate of cholecystitis was 17.4% (n = 20) during a median follow-up period of 1159 (range, 369–2774) days. Endoscopic biliary sphincterotomy did not significantly affect the recurrence rate of cholecystitis (P = .561). In multivariable analysis, cystic duct stones (P = .013) and PTGBD catheter migration before the prescheduled removal time (P = .002) were identified as independent risk factors for cholecystitis recurrence after PTGBD.To reduce post-PTGBD recurrence in cholecystitis, caution must be exercised to avoid inadvertent dislodging of the PTGBD catheter. In cases of cholecystitis with cystic duct stones, cholecystectomy should be considered only after careful assessment of postoperative risks. Instead, transluminal endoscopic gallbladder drainage could represent a promising option for the prevention of recurrent cholecystitis.     

Chemical ablation of the gallbladder using alcohol in cholecystitis after palliative biliary stenting

Chemical ablation of the gallbladder is effective in patients at high risk of complications after surgery. Percutaneous gallbladder drainage is an effective treatment for cholecystitis; however, when the drain tube cannot be removed because of recurrent symptoms, retaining it can cause problems. An 82-year-old woman presented with cholecystitis and cholangitis caused by biliary stent occlusion and suspected tumor invasion of the cystic duct. We present successful chemical ablation of the gallbladder using pure alcohol, through a percutaneous gallbladder drainage tube, in a patient who developed intractable cholecystitis with obstruction of the cystic duct after receiving a biliary stent. Our results suggest that chemical ablation therapy is an effective alternative to surgical therapy for intractable cholecystitis.     

Endoscopic ultrasonography‐guided cholecystogastrostomy in patients with unresectable pancreatic cancer using anti‐migratory metal stents: A new approach

Cholecystectomy is contraindicated in patients with comorbidities or unresectable cancer. Percutaneous transhepatic gallbladder drainage (PTGBD) is typically offered with response rates ranging from 56% to 100%, but has several risks such as bleeding, pneumothorax, pneumoperitoneum, bile leak, and/or catheter migration. Endoscopic transpapillary gallbladder drainage (ETGD) and endoscopic ultrasound‐guided transmural gallbladder drainage (EUS‐GBD) are alternative endoscopic modalities that have a technical feasibility, efficacy and safety profile comparable with PTGBD. In this report, we present the first case series of transgastric EUS‐GBD with placement of a fully covered self‐expandable metal stent with anti‐migratory fins. In three pancreatic cancercases with acute cholecystitis when ETGD was unsuccessful, there were no bile leaks or procedurally related complications. There were no acute cholecystitis recurrences. In conclusion, EUS‐GBD is a promising, minimally invasive treatment for acute cholecystitis. Additional comparative studies are needed to validate the benefit of this technique.     

Techniques of biliary drainage for acute cholecystitis: Tokyo Guidelines

The principal management of acute cholecystitis is early cholecystectomy. However, percutaneous transhepatic gallbladder drainage (PTGBD) may be preferable for patients with moderate (grade II) or severe (grade III) acute cholecystitis. For patients with moderate (grade II) disease, PTGBD should be applied only when they do not respond to conservative treatment. For patients with severe (grade III) disease, PTGBD is recommended with intensive care. Percutaneous transhepatic gallbladder aspiration (PTGBA) is a simple alternative drainage method with fewer complications; however, its clinical usefulness has been shown only by case-series studies. To clarify the clinical value of these drainage methods, proper randomized trials should be done. This article describes techniques of drainage for acute cholecystitis.     

Endoscopic transpapillary gallbladder drainage with replacement of a covered self-expandable metal stent

Endoscopic self-expandable metal stent (SEMS) placement has become a standard palliative therapy for pa- tients with malignant biliary obstruction. Acute cholecystitis after SEMS placement is a serious complication. We report a patient with an acute cholecystitis after covered SEMS placement, who was managed successfully with endoscopic transpapillary gallbladder drainage (ETGBD) and replacement of the covered SEMS. An 85-year-old man with pancreatic cancer suffered from acute cholecystitis after covered SEMS placement. It was impossible to perform percutaneous transhepatic gallbladder drainage. After removal of the covered SEMS with a snare, a 7Fr double pigtail stent was placed between the gallbladder and duodenum, subsequently followed by another covered SEMS insertion into the common bile duct beside the gallbladder stent. The cholecystitis improved immediately after ETGBD. ETGBD with replacement of the covered SEMS thus proved to be effective for treatment of patients with acute cholecystitis after covered SEMS placement.     

Endoscopic ultrasound gallbladder drainage: Patient selection,preparation, and performance

Acute cholecystitis is a common cause of hospital admissions and can result in critically ill patients. For those patients not amenable to cholecystectomy, endoscopic drainage via transpapillary cystic duct stenting or transmural drainage offers a temporizing method for urgent gallbladder decompression. Endoscopic ultrasonography (EUS) and the development of novel lumen apposing metal stents can allow for more permanent drainage with comparable outcomes to percutaneous transhepatic catheters. The merits of this approach including the technical and clinical advantages of EUS-guided drainage are discussed further in this review article.     

2 Imaging and intervention in patients with acute right upper quadrant disease

Because of the high diagnostic yield, its widespread availability and the possibility of bedside examinations, US has become the imaging modality of choice in patients with acute right upper quadrant pain caused by inflammatory disorders such as liver abscesses, acute cholangitis and acute cholecystitis. Computed tomography (CT) can be reserved for more complex cases. US, often in combination with fluoroscopy, is also widely used to control interventions. In patients with liver abscesses the therapeutic strategy is determined by the size of the abscess, its uni- or multifocal presentation and the causative micro-organisms cultured after diagnostic percutaneous aspiration. Small-sized pyogenic abscesses (<3 cm), most fungal and amoebic abscesses can be treated medically. Large-sized pyogenic abscesses should be drained percutaneously and can be cured in 75–90%. Surgery should be restricted to patients with prolonged sepsis after percutaneous drainage and patients with infected pre-existing hepatic lesions.In patients with acute cholangitis drainage of the infected bile is essential. Invasive imaging such as percutaneous or endoscopic cholangiography should only be done with the intention to drain. The use of endoscopic procedures such as nasobiliary drainage, stent placement and sphincterotomy has decreased mortality rates dramatically. Percutaneous drainage should be considered in patients in whom endoscopic procedures fail. Surgery may have a place in the treatment of bile duct obstruction which causes cholangitis.In patients with suspected acute cholecystitis, imaging modalities such as cholescintigraphy and CT can be reserved for patients with inconclusive sonographic studies and more complex cases. The contribution of percutaneous gallbladder aspiration and culture to diagnose acute cholecystitis seems limited. Percutaneous cholecystostomy is an effective procedure with a low morbidity and mortality for high-risk patients. The drainage catheter in the gallbladder does not interfere with cholecystectomy at a later stage in patients with calculous cholecystitis. In most patients with acalculous cholecystitis, percutaneous cholecystectomy provides a definitive treatment.     

A case of superficial bile duct carcinoma showing extensive intraductal spread without bile duct stenosis, diagnosed by intraductal ultrasonography]

We report a case of superficial bile duct carcinoma showing extensive intraductal spread without dilatation of the bile duct in which diagnosis was established preoperatively by transpapillary forceps biopsy and intraductal ultrasonography. A 78-year-old man was given a diagnosis of acute cholecystitis, and percutaneous transhepatic gallbladder drainage (PTGBD) was performed. Cholangiography via the PTGBD tube revealed a tiny irregularity in the hilar bile duct. Transpapillary intraductal ultrasonography showed that this irregularity extended from the intrahepatic bile duct to the middle of the bile duct. Bile duct biopsy revealed malignancy, and thus bile duct resection and hepaticojejunostomy were performed. Histological examination verified a well-differentiated adenocarcinoma confined to the epithelium and the fibromuscular layer.     

Endoscopic naso-gallbladder drainage versus gallbladder stenting before cholecystectomy in patients with acute cholecystitis and a high suspicion of choledocholithiasis: a prospective randomised preliminary study

Objective Endoscopic transpapillary gallbladder drainage using a nasocystic tube or plastic stent has been attempted as an alternative to percutaneous drainage for patients with acute cholecystitis who are not candidates for urgent cholecystectomy. We aimed to assess the efficacy of single-step endoscopic drainage of the common bile duct and gallbladder, and to evaluate which endoscopic transpapillary gallbladder drainage method is ideal as a bridge before elective cholecystectomy. Materials and methods From July 2011 to December 2014, 35 patients with acute moderate-to-severe cholecystitis and a suspicion of choledocholithiasis were randomly assigned to the endoscopic naso-gallbladder drainage (ENGBD) (n?=?17) or endoscopic gallbladder stenting (EGBS) (n?=?18) group. Results Bile duct clearance was performed successfully in all cases. No significant differences were found between the ENGBD and EGBS groups in the technical success rates [82.4% (14/17) vs. 88.9% (16/18), p?=?0.658] and clinical success rates [by intention-to-treat analysis: 70.6% (12/17) vs. 83.3% (15/18), p?=?0.443; by per protocol analysis of technically feasible cases: 85.7% (12/14) vs. 93.8% (15/16), p?=?0.586]. Three ENGBD patients and two EGBS patients experienced adverse events (p?=?0.658). No significant differences were found in operation time or rate of conversion to open cholecystectomy. Conclusions Single-step endoscopic transpapillary drainage of the common bile duct and gallbladder seems to be an acceptable therapeutic modality in patients with acute cholecystitis and a suspicion of choledocholithiasis. There were no significant differences in the technical and clinical outcomes between ENGBD and EGBS as a bridge before cholecystectomy.     

NASOGALLBLADDER DRAINAGE FOR MIRIZZI’S SYNDROME

The authors experienced a case of Mirizzi’s syndrome successfully treated with endoscopic nasogallbladder drainage (ENGBD). The patient was a 63‐year‐old man. He was admitted with abdominal pain and jaundice. Laboratory data indicated leukocytosis and elevation of serum bilirubin level. Abdominal ultrasound showed marked swelling of gallbladder and debris in the gallbladder, therefore, the authors strongly suspected Mirizzi’s syndrome. He had past history of acute myocardial infarction and treated with anticoagulation therapy. Then, the authors couldn’t perform surgical removal or percutaneous transhepatic drainage, and tried endoscopic transpapillary drainage. Endoscopic retrograde cholangiopancreatography revealed smooth stricture in the superior portion of common bile duct and occlusion of the cystic duct, and ENGBD was then performed. After ENGBD, his complaints, laboratory data, swelling of gallbladder and stricture of common bile duct were all remarkably improved.     

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient’s general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient’s general medical condition.     

Peritoneal bleeding due to percutaneous transhepatic gallbladder drainage:An autopsy report

A 77-year-old man underwent percutaneous transhepatic gallbladder drainage(PTGBD) for acute cholecystitis as a preoperative procedure;however,he suddenly suffered cardiopulmonary arrest 4 h after the PTGBD and died.There were three centesis scars for the PTGBD,and only one pathway from the most dorsal centesis scar reached the gallbladder.Microscopically,the PTGBD pathway crossed and injured the intrahepatic arterial wall,and hepatic parenchymal bleeding extended along the PTGBD pathway to the inferior surface of the liver.Blood flowed to the peritoneal cavity through a small gap between the liver and gallbladder.Consequently,the PTGBD caused lethal bleeding.When the percutaneous transhepatic cholangio drainage/PTGBD pathway runs close to vessels near the liver surface,it might be necessary to deal with the possibility of rapid and lethal peritoneal bleeding.     

Percutaneous transcatheter occlusion of cystic duct stump in postcholecystectomy bile leakage

Postoperative cystic duct fistula is an uncommon complication after cholecystectomy. Nonoperative management includes endoscopic retrograde or percutaneous transhepatic biliary drainage, and percutaneous catheter drainage of fluid collections. Transcatheter occlusion of the leaking cystic duct remnant proved a valuable alternative treatment when biliary stenting failed for technical reasons.     

Endoscopic ultrasonography‐guided gallbladder drainage for acute cholecystitis: From evidence to practice

With the evolution of the linear echoendoscope and the improved ability to direct a needle within the field of interest, the therapeutic potential of endoscopic ultrasonography (EUS) has greatly expanded. Endoscopic ultrasonography‐guided transmural gallbladder drainage (EUS‐GBD) may be the next frontier for therapeutic EUS. Since EUS‐GBD was first described in 2007, recent reports have suggested it as an alternative to external gallbladder drainage for acute cholecystitis. EUS‐GBD includes EUS‐guided transmural nasogallbladder drainage, EUS‐guided gallbladder aspiration, and EUS‐guided transmural gallbladder stenting. Indications for the EUS‐GBD technique as currently practiced, including equipment, technical details, complications, and efficacy are herein reviewed.     

An extrahepatic bile duct metastasis from a gallbladder cancer mimicking Mirizzi's syndrome

We report a case of an extrahepatic bile duct metastasis from a gallbladder cancer that mimicked Mirizzi's syndrome on cholangiography. A 67-yr-old woman was admitted to our hospital with a diagnosis of acute calculous cholecystitis. As obstructive jaundice developed after the admission, percutaneous transhepatic biliary drainage was performed to ameliorate the jaundice and to evaluate the biliary system. Tube cholangiography revealed bile duct obstruction at the hepatic hilus, and extrinsic compression of the lateral aspect of the common hepatic duct, with nonvisualization of the gallbladder. No impacted cystic duct stone was visualized on CT or ultrasonography. Laparotomy revealed a gallbladder tumor as well as an extrahepatic bile duct tumor. We diagnosed that the latter was a metastasis from the gallbladder cancer, based on the histopathological features. This case is unique in that the extrahepatic bile duct metastasis obstructed both the common hepatic duct and the cystic duct, giving the appearance of Mirizzi's syndrome on cholangiography. Metastatic bile duct tumors that mimic Mirizzi's syndrome have not been previously reported. The presence of this condition should be suspected in patients with the cholangiographic features of Mirizzi's syndrome, when the CT or ultrasonographic findings fail to demonstrate an impacted cystic duct stone.     

Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018

The Tokyo Guidelines 2013 (TG13) include new topics in the biliary drainage section. From these topics, we describe the indications and new techniques of biliary drainage for acute cholangitis with videos. Recently, many novel studies and case series have been published across the world, thus TG13 need to be updated regarding the indications and selection of biliary drainage based on published data. Herein, we describe the latest updated TG13 on biliary drainage in acute cholangitis with meta‐analysis. The present study showed that endoscopic transpapillary biliary drainage regardless of the use of nasobiliary drainage or biliary stenting, should be selected as the first‐line therapy for acute cholangitis. In acute cholangitis, endoscopic sphincterotomy (EST) is not routinely required for biliary drainage alone because of the concern of post‐EST bleeding. In case of concomitant bile duct stones, stone removal following EST at a single session may be considered in patients with mild or moderate acute cholangitis except in patients under anticoagulant therapy or with coagulopathy. We recommend the removal of difficult stones at two sessions after drainage in patients with a large stone or multiple stones. In patients with potential coagulopathy, endoscopic papillary dilation can be a better technique than EST for stone removal. Presently, balloon enteroscopy‐assisted endoscopic retrograde cholangiopancreatography (BE‐ERCP) is used as the first‐line therapy for biliary drainage in patients with surgically altered anatomy where BE‐ERCP expertise is present. However, the technical success rate is not always high. Thus, several studies have revealed that endoscopic ultrasonography‐guided biliary drainage (EUS‐BD) can be one of the second‐line therapies in failed BE‐ERCP as an alternative to percutaneous transhepatic biliary drainage where EUS‐BD expertise is present.