905 Endoscopic Ultrasound vs. Endoscopic Trans-Papillary vs. Percutaneous Gallbladder Drainage in High-Risk Acute Cholecystitis Patients: A Systematic Review and Indirect Comparative Meta-Analysis

Abstract

INTRODUCTION: Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound guided gallbladder drainage (EUSGBD) are alternative to percutaneous gallbladder drainage (PCGBD) in the management of acute cholecystitis in patients deemed unfit for surgery. The role of endoscopy in the treatment algorithm has not been confirmed due to limited data and conflicting results. METHODS: We searched multiple databases from inception through May2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients high-risk for surgery. Our goals were to indirectly compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence with ETGBD, EUSGBD, and PCGBD by meta-analysis methods. RESULTS: 15131 patients from 72 studies were analyzed. 22 studies (1223 patients), 14 studies (557 patients), and 46 studies (13351 patients) were treated by ETGBD, EUSGBD, and PCGBD respectively. The pooled technical and clinical successes of EUSGBD were statistically superior to ETGBD [95.3% (95%CI 92.8-96.9, I2 = 0) vs 83% (95%CI 80.1-85.5, I2 = 29), P = 0.001] and [96.7% (95% CI 94-98.2, I2 = 0) vs 88.1% (95%CI 83.6-91.4, I2 = 50), P = 0.001], respectively. Pooled clinical success with EUSGBD was statistically superior to PCGBD [89.3% (95%CI 86.6-91.5, I2 = 84), P = 0.001]. The pooled rate of disease recurrence was comparable between ETGBD and EUSGBD, but more with PCGBD (10.8%, 95%CI 8.4-13.9, P = 0.001). The pooled rate of all adverse events were comparable between the groups (Table 1). Bleeding and perforation was statistically more with EUSGBD [4.3% (95%CI 2.7-6.8), P = 0.03; 3.7% (95%CI 2.3-6), P = 0.004; respectively], pancreatitis was statistically more with ETGBD [5.1% (95%CI 3.5-7.3, P = 0.003], and stent-migration was more with PCGBD 7.4% (95%CI 5.5-10, P = 0.01) (Table 2). All cause mortality was 9.8% (7.7-12.4) with PCGBD and was statistically significant when compared to EUSGBD (3.8%, 2-7, P = 0.006). CONCLUSION: This is the largest and most comprehensive meta-analysis indirectly comparing ETGBD, EUSGBD and PCGBD in the treatment of acute cholecystitis in surgically unfit patients. Based on our analysis, EUSGBD demonstrates superior clinical success when compared to ETGBD and/ or PCGBD, albeit with increased risk to perforation and bleeding. Given the low heterogeneity and the strength of the data, EUSGBD should be considered the first line approach in this patient population.