Percutaneous versus endoscopic approach in treatment of acute cholecystitis

Abstract

To the Editor: I have read with great interest the article by Jang et al,1Jang J.W. Lee S.S. Park do H. et al.Feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients unsuitable for cholecystectomy.Gastrointest Endosc. 2011; 74: 176-181Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar which evaluates the technical feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients with acute cholecystitis who are unsuitable for cholecystectomy. The authors concluded that this method could be a feasible and safe alternative to treatments such as percutaneous cholecystostomy (PC) in patients with acute cholecystitis who were unsuitable for cholecystectomy. I have a long experience in performing PC, and I wish to add some comments regarding this topic. From my point of view, PC has several advantages compared with covered self-expandable metal stent placement in the management of acute cholecystitis: 1The US-guided percutaneous approach to the gallbladder bed is much easier, with less trauma for patients compared with the EUS-guided approach, with similar or better effects.2It is better to drain necrotic (very often infected) content out of rather than into the GI tract.3The monitoring and catheter manipulation in patients with infective complications or other drainage problems, vigorous irrigation of the gallbladder bed via catheter with normal saline solution, and the microbiologic and biochemical analysis of obtained content are all very difficult or impossible to perform by the endoscopic approach, unlike with a PC procedure.4PC requires much simpler training compared with endoscopic management (it requires both endoscopic and US skills) of acute cholecystitis. In conclusion, despite the fact that the transgastric approach is suitable, because the gallbladder lies adjacent to the stomach, I believe that PC has several advantages and should be considered as the first choice option in the therapeutic spectrum for acute cholecystitis in patients who are unsuitable for surgical cholecystectomy. Feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients unsuitable for cholecystectomyGastrointestinal EndoscopyVol. 74Issue 1PreviewAlthough early laparoscopic cholecystectomy is the treatment of choice for patients with acute cholecystitis, percutaneous cholecystostomy has been performed in patients unsuitable for cholecystectomy. EUS-guided transgastric/transduodenal gallbladder drainage by using a plastic stent and/or nasobiliary drainage may be an alternative effective treatment for these patients, but bile leakage into the peritoneal space causing bile peritonitis is not uncommon during placement of a plastic stent. Full-Text PDF ResponseGastrointestinal EndoscopyVol. 75Issue 1PreviewWe would like to thank Dr Enver Zerem for his insightful editorial to our article. We would like to provide some additional perspective on his commentary. Full-Text PDF