EUS-guided gallbladder drainage with a lumen-apposing metal stent versus endoscopic transpapillary gallbladder drainage for the treatment of acute cholecystitis (with videos)

Abstract

There is an evolving role for EUS-guided transmural gallbladder (GB) drainage. Endoscopic transpapillary GB drainage is a well-established, nonoperative treatment for acute cholecystitis. We compared the outcomes of 78 cases of EUS-guided versus transpapillary GB drainage at a single, U.S.-based, high-volume endoscopy center. This was a retrospective analysis performed from May 2013 to January 2018, identified from a database of nonoperative patients with acute cholecystitis. Both electrocautery-enhanced and nonelectrocautery-enhanced lumen-apposing metal stents were used. For transpapillary drainage, guidewire access was obtained and then a transpapillary 7F× 15-cm double-pigtail plastic stent was placed. In patients who had successful transpapillary or transmural drainage, demographics data were similar. Technical success was observed in 39 of 40 patients (97.5%) who underwent first attempt at EUS-guided drainage versus 32 of 38 patients (84.2%) for first-attempt transpapillary drainage (adjusted odds ratio, 9.83; 95% confidence interval, .93-103.86). Clinical success was significantly higher with EUS drainage in 38 of 40 patients (95.0%) versus transpapillary drainage in 29 of 38 patients (76.3%) (adjusted odds ratio, 7.14; 95% confidence interval, 1.32-38.52). Recurrent cholecystitis was lower in the EUS-guided drainage group (2.6% vs 18.8%, respectively; P= .023) on univariate analysis but only trended to significance in a multiple regression model. Duration of follow-up, reintervention rates, hospital length of stay, and overall adverse event rates were similar between groups. EUS-guided GB drainage results in a higher clinical success rate compared with transpapillary drainage and may be associated with a lower recurrence rate of cholecystitis. However, transpapillary drainage should be considered as the first-line treatment for patients who are surgical candidates but require temporizing measures or require an ERCP for alternative reasons.