EUS-guided Gallbladder Drainage Research Articles

166 SAFETY AND EFFICACY OF EUS-GUIDED GALLBLADDER DRAINAGE (EUS-GBD) COMBINED WITH ERCP IN THE SAME SESSION

ERCP is increasingly being combined in a single-session with other endoscopic procedures such as EUS (staging, screening for CBD stones, rendezvous for failed cannulation) duodenal stenting or cholangioscopy. EUS-guided gallbladder drainage (EUS-GBD) is an emerging option for acute cholecystitis in non-surgical candidates. Patients with acute cholecystitis often need CBD stone removal. Combination of ERCP for CBD stones and EUS-GBD might be appealing in some patient subsets, but there is virtually no objective evidence to support this combined approach to gallstone disease. To assess the safety and efficacy of EUS-GBD combined with ERCP in the same session. Single-center retrospective cohort study comparing outcomes of EUS-GBD alone to those of ERCP combined with EUS-GBD in the same session between June 2011 and May 2017. Lumen-apposing metal stent (LAMS, Axios®) were used in both groups. Exclusion criteria: ERCP or EUS-GBD used for salvage of one another (ie, transcystic GB drainage after failed EUS-GBD or EUS-GBD for failed biliary drainage at ERCP), EUS-guided biliary drainage (EUS-BD) in the same session, and ERCP within 5 days (before/after) EUS-GBD. Epidemiologic, procedural, and clinical outcome data were analyzed with Wilcoxon, Chi-square and Fisher tests where appropriate. Primary endpoints were rates of technical success, clinical success and adverse events. Sixty four consecutive patients underwent EUS-GBD between June 2011 and May 2017. 18 Patients were excluded: in 11 the indication for either ERCP or EUS-GBD was salvage of a failed tandem procedure, 5 had EUS-guided biliary drainage in the same session and a further 3 had another ERCP within 5 days of the index procedure. Forty five patients met inclusion/exclusion criteria: 24 EUS-GBD and 21 EUS-GBD combined with ERCP. Baseline characteristics were comparable in both groups. There were no significant differences in technical (100% vs 91.7%) and clinical success rates (90.5% vs 91.7%) of EUS-GBD in the combined versus the single procedure groups. The rate of adverse events (19.8% vs 20.9%) and the rate of technical issues (14.3% vs 37.5%; p=0.10) during LAMS deployment were also comparable. Results are detailed in Table 1. Technical success of ERCP was 100%. Details of ERCP are described in Table 2. While ERCP combined with EUS-GBD maintains similar rates of technical and clinical success to EUS-GBD alone, a combined procedure does not appear to increase adverse events. Despite the limitations of our study, these findings are encouraging and warrant further evaluation before this therapeutic approach can be generalized.Tabled 1Table 1.EUS-GBD+ERCP (n=21)EUS-GBD (n=24)pMedian age (IQR)85.3 (78-89)83.9 (78.6-89.9)0.70Male, n (%)10 (47.6%)13 (54.2%)0.66Baseline disease1-Benign, n (%)18 (85.7%)20 (83.3%)-Malignant, n (%)3 (14.3%)4 (16.7%)Indication24 (100%)0.21-Cholecystitis, n (%)19 (90.5%)-Coledocolithiasis, n (%)1 (4.8%)-Biliary decompression1 (4.8%)Technical issues during LAMS deployment, n (%)3 (14.3%)9 (37.5%)0.10Adverse events, n (%)4 (19.8%)5 (20.9%)1Clinical success, n (%)19 (90.5%)22 (91.7%)1Technical success, n (%)21(100%)22(91.7%)0.49 Open table in a new tab Tabled 1Table 2.Total (n=21)Indicacion-Cholecystitis, n (%)8 (38.1%)-Cholangitis, n (%)3 (14.3%)-Coledocholithiasis, n (%)6 (28.6%)-Benign stricture, n (%)1 (4.8%)-Malignant stricture, n (%)3 (14.3%)Sphincterotomy, n (%)17 (81%)Stone extraction, n (%)17 (81%)Precut, n (%)4 (19.1%)Biliary stent, n (%)5 (23.8%)Pancreatic stent, n (%)2 (11.1%) Open table in a new tab

Su1401 FEASIBLITY AND SAFETY OF EUS-GUIDED GALLBLADDER DRAINAGE WITH NEW LUMEN APPOSING METAL STENT (SPAXUS) IN PATIENTS WITH ACUTE CHOLECYSTITIS WHO ARE UNSUITABLE FOR CHOLECYSTECTOMY

Endoscopic ultrasound (EUS) guided gallbladder drainage increasingly accepted as an effective alternative to percutaneous drainage in a patient who needs drainage for acute cholecystitis. Stent migration is the main obstacles in EUS guided gallbladder drainage (EUS-GBD) with conventional biliary metal stent. To overcome this adverse event, a lumen apposing metal stent (LAMS) has recently been introduced in this procedure. In this study, we have evaluated the feasibility and safety of newly developed LAMS (SPAXUS®) in patients with acute cholecystitis who were unsuitable for cholecystectomy. Between Mar 2017 to Oct 2017, a total of 22 patients with acute cholecystitis who did not respond to initial medical treatment and were unsuitable cholecystectomy were enrolled. We evaluated technical, clinical success and adverse event profiles. EUS-GBD with newly developed LAMS was technically and clinically successful in 21/22 patients. Mean procedure time was 12.5 ± 5.0 minutes. Purpose of EUS-GBD was urgent drainage in 17 and establish of internal drainage before percutaneous transhepatic gallbladder drainage (P-GBD) removal in 5 patients. Early adverse events were occurred in 2/21 patients (1 stent occlusion by stone and 1 pyloric ring obstruction by proximal flange of SPAXUS). In the cases with pyloric ring obstruction, pyloric stent was applied temporarily. In 10 patients, direct cholecystoscopy was conducted one or two days after EUS-GBD Late adverse event of stent occlusion developed in 1/21 patients. Stent migration was not observed during follow up period. P-GBD removal was possible in all 5 patients who underwent EUS-GBD for internal drainage before P-GBD removal. Mean stent patency duration was 162.5 days (95% CI 146.37-178-63). EUS-GBD with new lumen apposing metal stent is technically feasible and shows acceptable safety profile in patients with acute cholecystitis who has high surgical risk.

A primary study on curative effects of endoscopic ultrasound-guided gallbladder drainage for patients with acute cholecystitis and high surgical risk

Objective To investigate the efficacy and safety of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) for patients with acute cholecystitis, who are unfit for cholecystectomy. Methods Patients who underwent EUS-GBD at Hangzhou First People′s Hospital from April 2015 to December 2016 were enrolled in this study. Clinical data were collected, and effectiveness and complications were analyzed. Results EUS-GBD was achieved in all 5 patients, and the mean procedure time of EUS-GBD was 26.0±3.1 min. Double pigtail plastic stents were successfully placed in 4 patients. A nasobiliary drainage tube was placed in 1 patient and the tube was endoscopically cut 5 days after procedure acting as internal drainage. All patients recovered without complications and no procedure-related death occurred. During the follow-up period (46-692 d), no patient experienced recurrent cholecystitis and stent migration. Conclusion At an experienced endoscopic center, EUS-GBD is a safe, effective and minimally invasive method for patients with acute cholecystitis and high surgical risk. Key words: Cholecystitis, acute; Endosonography; Stents; Endoscopic gallbladder drainage

Endoscopic ultrasound-guided gallbladder drainage: Results of long-term follow-up.

Background/Aim:Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged using a self-expandable metallic stent (SEMS). The aim of the study was to evaluate the long-term outcomes of this procedure. In addition, the efficacy and safety of EUS-GBD with SEMS were assessed.Patients and Methods:Thirteen consecutive patients who underwent EUS-GBD for acute cholecystitis between February 2014 and September 2016 were included in this retrospective study. EUS-GBD was performed under the guidance of EUS and fluoroscopy, through puncturing the gallbladder with a needle, inserting a guidewire, dilating the puncture hole, and placing a SEMS.Results:The rates of technical success, functional success, and adverse events were 100%, 92.3% and 7.7%, respectively. The median procedure time was 26.9 min (range 19–42 min). The median follow-up time was 240 days (range 14–945 days) and during this follow-up period recurrence of cholecystitis was observed in one patient (7.7%).Conclusion:EUS-GBD with a SEMS is a possible alternative treatment for acute cholecystitis in high surgical risk patients. Long-term outcomes after EUS-GBD were promising.

EUS-guided gallbladder drainage vs. percutaneous gallbladder drainage.

EUS-guided gallbladder drainage vs. percutaneous gallbladder drainage.

Technical considerations in EUS-guided gallbladder drainage.

Technical considerations in EUS-guided gallbladder drainage.

EUS-guided gallbladder drainage and gallbladder interventions in China.

EUS-guided gallbladder drainage and gallbladder interventions in China.

Long-term outcomes after EUS-guided gallbladder drainage.

Long-term outcomes after EUS-guided gallbladder drainage.

Development of EUS-guided gallbladder drainage and current indications.

Development of EUS-guided gallbladder drainage and current indications.

Current Status of Endoscopic Gallbladder Drainage.

The gold standard for treatment of acute cholecystitis is laparoscopic cholecystectomy. However, cholecystectomy is often not suitable for surgically unfit patients who are too frail due to various co-morbidities. As such, several less invasive endoscopic treatment modalities have been developed to control sepsis, either as a definitive treatment or as a temporizing modality until the patient is stable enough to undergo cholecystectomy at a later stage. Recent developments in endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with endoscopic ultrasound EUS-specific stents having lumen-apposing properties have demonstrated potential as a definitive treatment modality. Furthermore, advanced gallbladder procedures can be performed using the stents as a portal. With similar effectiveness as percutaneous transhepatic cholecystostomy and lower rates of adverse events reported in some studies, EUS-GBD has opened exciting possibilities in becoming the next best alternative in treating acute cholecystitis in surgically unfit patients. The aim of this review article is to provide a summary of the various methods of gallbladder drainage GBD with particular focus on EUS-GBD and the many new prospects it allows.

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis with a silicone-covered nitinol short bilaterally flared stent: a case series.

Background and study aim Gallbladder drainage in patients with cholecystitis who are unsuitable for surgery may be performed by endoscopic ultrasound (EUS)-guided placement of specifically designed fully covered metal stents. We describe the first case series of patients treated with a silicone-covered nitinol stent with bilateral anchor flanges. Patients and methods Data from consecutive patients with acute cholecystitis who were deemed unsuitable candidates for surgery were collected. The stent placement procedure was performed in two tertiary endoscopy centers by four experienced endoscopists. Technical and clinical success rates, as well as adverse events and clinical outcome at follow-up, were assessed. Results EUS-guided drainage for cholecystitis was performed in 16 patients (mean age 84 years; nine males). Technical and clinical success rates were 100 % (16/16) and 94 % (15/16), respectively; an early failure due to stone impaction occurred in the remaining case and required placement of a new stent. Symptom relief occurred in 11/15 cases (73 %) within 1 day, and within 2 days in the remaining 4 patients. Bleeding occurred in two patients (13 %): in one patient intraprocedural bleeding was successfully stopped during endoscopy; and delayed bleeding occurred in one patient requiring arterial embolization for catastrophic bleeding (patient died 10 days later). No cases of cholecystitis recurrence or biliary obstruction were observed during a median follow-up of 112 days (range 49 – 180 days). Conclusions Our data showed that EUS-guided gallbladder drainage with a specially designed stent is feasible and successful in patients with acute cholecystitis who are unfit for surgery.

EUS-guided Gall Bladder Drainage in Severe Liver Disease: A Single-center Experience in Critically Ill Cirrhotics.

Background and Aims: Acute calculous cholecystitis with impending gall bladder perforation in severe liver diseases including decompensated cirrhosis and acute-on-chronic liver failure (ACLF) is difficult to manage, due to the procedures such as cholecystectomy and per cutaneous cholecystostomy being associated with high risk and complications in these patients.Methods: Four cases of severe liver disease with acute calculous cholecystitis who presented to the Institute of Liver and Biliary Sciences (New Delhi, India) for further management were included in the study if they underwent endoscopic ultrasound-guided gall bladder drainage (EUS-GBD). The patients were followed up for a minimum of 3 months and outcomes were recorded.Results: Four cases of severe liver disease (three ACLF and one decompensated cirrhosis), with model for end-stage liver disease scores of 24, 26, 23 and 25 respectively, presented with acute calculous cholecystitis (Tokyo grade III) and systemic sepsis (high total leukocyte counts). Their international normalized ratios were 2.3, 2.6, 2.2 and 2.9 respectively, and two were in shock, requiring inotropes at presentation. Ultrasonography of the abdomen confirmed hugely distended gall bladder with stone impacted at the neck and moderate ascites. All these cases underwent EUS-GBD by linear echo endoscope, and had the gastric wall punctured in the antrum using a 19G access needle followed by dilatation of the tract using controlled radial expansion balloon and Sohendra dilator. In three cases, the plastic stents were placed. In the fourth case, a Nagi stent was placed. All the patients recovered and were discharged within a week.Conclusions: EUS-GBD is challenging in severe liver disease but represents a life-saving procedure, and hence can be attempted in such critically ill patients with utmost care and precaution.

胆管内金属ステント（self-expandable metallic stent：SEMS）留置後の胆嚢炎に対してPTGBD後に超音波内視鏡下胆嚢ドレナージ（EUS-guided gallbladder drainage：EUS-GBD）による内瘻化を施行した1例

胆管内金属ステント（self-expandable metallic stent：SEMS）留置後の胆嚢炎に対してPTGBD後に超音波内視鏡下胆嚢ドレナージ（EUS-guided gallbladder drainage：EUS-GBD）による内瘻化を施行した1例

Mo1262 Cholecystectomy After Endoscopic Ultrasound Guided Gallbladder Drainage? Absolutely!

Mo1262 Cholecystectomy After Endoscopic Ultrasound Guided Gallbladder Drainage? Absolutely!

Mo1236 EUS-Guided Gallbladder Drainage Reduces Late Adverse Event and Need for Re-Intervention Compared With Percutaneous Cholecystostomy in Patents Who Are Not Eligible for Surgery

Mo1236 EUS-Guided Gallbladder Drainage Reduces Late Adverse Event and Need for Re-Intervention Compared With Percutaneous Cholecystostomy in Patents Who Are Not Eligible for Surgery

Endoscopic ultrasonography-guided biliary and pancreatic duct interventions.

Drainage of obstructed bile duct and pancreatic duct under endoscopic ultrasonography (EUS) guidance has evolved into viable techniques suitable for patients with failed endoscopic retrograde cholangiopancreatography (ERCP) and/or altered surgical anatomy. One of the major advantages of EUS guidance is the possibility of multiple access points depending upon patient and ductal anatomy. Unlike ERCP, an approachable papilla is not a requisite for successful EUS-guided biliary or pancreatic ductal drainage. Moreover, as the access is away from the papilla, there is the possibility of reduced pancreatitis. A variety of procedures have become available for EUS-guided drainage, and it is important to develop standard terminology and procedural details. EUS-specific stents, including lumen-apposing metal stents have recently become available, and are likely to impact the outcomes of these procedures. Available data show a high success rate and acceptable adverse event rate for EUS-guided biliary drainage. Success rate appears to be low for pancreatic duct drainage because of a variety of reasons. Outcomes of EUS-guided biliary drainage appear equivalent to percutaneous drainage and ERCP. EUS-guided gallbladder drainage appears promising for patients requiring gallbladder drainage but unfit for surgery. Further large controlled studies are needed to evaluate the exact role of these procedures.

EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device

In high-risk surgical patients, the treatment of choice of acute cholecystitis is percutaneous transhepatic gallbladder drainage (PTGBD). Recently, a novel endoscopic device containing a lumen-apposing metal stent with an electrocautery (ECE-LAMS) on the tip has been developed. High-risk surgical patients with acute cholecystitis who underwent EUS-guided gallbladder drainage (EUS-GBD) with the novel device were retrospectively retrieved from 7 tertiary care referral centers. Main endpoints were technical and clinical success rates, rate of procedural adverse events, and short- and long-term adverse events. Seventy-five patients (mean age, 75 ± 11 years; 36 men) underwent EUS-GBD. The procedure was technically and clinically successful in 98.7% and 95.9% of cases, respectively. Three patients without resolution of cholecystitis died, and 2 patients had procedure-related adverse events: 1 perforation requiring surgery and 1 major bleeding resolved conservatively. The mean follow-up for the entire cohort was 201 ± 226 days. Seven patients (9.6%) died within the first 30 days; 50 patients (71.4%) were alive at the last date of follow-up. Short- and long-term adverse events occurred in 6 patients: 3 had recurrent cholecystitis, 2 had migration of the stent, and 1 developed Bouveret syndrome, all managed nonsurgically. Overall, 8 adverse events (10.7%) occurred in the entire cohort of patients. The novel ECE-LAMS for high-risk surgical patients with acute cholecystitis is safe, with a high technical and clinical success rate. Future multicenter studies comparing EUS-GBD versus PTGBD are warranted to determine which procedure is safer and clinically more effective for patients with high surgical risk acute cholecystitis.

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis: Long-term outcomes after removal of a self-expandable metal stent

AIMTo assess the long-term outcomes of this procedure after removal of self-expandable metal stent (SEMS). The efficacy and safety of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with SEMS were also assessed.METHODSBetween January 2010 and April 2015, 12 patients with acute calculous cholecystitis, who were deemed unsuitable for cholecystectomy, underwent EUS-GBD with a SEMS. EUS-GBD was performed under the guidance of EUS and fluoroscopy, by puncturing the gallbladder with a needle, inserting a guidewire, dilating the puncture hole, and placing a SEMS. The SEMS was removed and/or replaced with a 7-Fr plastic pigtail stent after cholecystitis improved. The technical and clinical success rates, adverse event rate, and recurrence rate were all measured.RESULTSThe rates of technical success, clinical success, and adverse events were 100%, 100%, and 0%, respectively. After cholecystitis improved, the SEMS was removed without replacement in eight patients, whereas it was replaced with a 7-Fr pigtail stent in four patients. Recurrence was seen in one patient (8.3%) who did not receive a replacement pigtail stent. The median follow-up period after EUS-GBD was 304 d (78-1492).CONCLUSIONEUS-GBD with a SEMS is a possible alternative treatment for acute cholecystitis. Long-term outcomes after removal of the SEMS were excellent. Removal of the SEMS at 4-wk after SEMS placement and improvement of symptoms might avoid migration of the stent and recurrence of cholecystitis due to food impaction.

Feasibility of conversion of percutaneous cholecystostomy to internal transmural endoscopic ultrasound-guided gallbladder drainage.

Background/Aim:Percutaneous cholecystostomy [percutaneous transhepatic gallbladder drainage (PTGBD)] is the treatment of choice in surgically unfit patients with acute cholecystitis. However, PTGBD tube removal after symptoms resolution results in 41–46% recurrence. This study aims to demonstrate the feasibility of the conversion of PTGBD to transmural endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic stents in patients unfit for cholecystectomy.Patients and Methods:Patients who underwent internal transmural EUS-GBD as a conversion from PTGBD were reviewed. EUS-GBD was performed after the improvement of cholecystitis due to recurrent cholecystitis and PTGBD intolerance. One or two 7-Fr double pigtail plastic stent insertion with or without temporary endoscopic naso-gallbladder drainage (ENGBD) insertion was performed.Results:Six patients (age 61–88), with three cases of acute cholecystitis after metallic biliary stenting and three cases of calculus cholecystitis, who underwent PTGBD were included. EUS-GBD was performed 10–63 days after PTGBD, using one plastic stent in five cases, two stents in one case, with temporary ENGBD in two cases. The technical success and clinical success were achieved and the PTGBD tubes were subsequently removed in all patients. All ENGBD tubes were removed within 5 days after insertion. Bile leak with peritonitis was demonstrated in one case, which was treated conservatively. No recurrent cholecystitis was seen during 3–26 months of follow-up.Conclusion:The conversion of percutaneous cholecystostomy to internal transmural EUS-GBD with plastic stents is feasible for patients unfit for cholecystectomy. However, more studies are still needed to confirm the results.

Feasibility of per-oral cholecystoscopy and advanced gallbladder interventions after EUS-guided gallbladder stenting (with video)

The recent development of EUS-guided gallbladder drainage (EGBD) with a lumen-apposing stent has made endoscopic assessment and advanced gallbladder interventions via the stent possible. The aim of this study was to assess the feasibility and safety of per-oral cholecystoscopy and the types of gallbladder interventions that can be performed. This was a retrospective review conducted in the Prince of Wales Hospital from June 2012 to March 2016. All patients who had acute cholecystitis with EGBD were included. Cholecystoscopy was performed 1 to 3 months after stent insertion. Patients' demographic data, technical success, types of intervention, and adverse events were recorded. Twenty-nine cholecystoscopies were performed in 25 patients. Twenty-seven of 29 cholecystoscopies were successful (93.1%). Magnifying endoscopy was performed in 10 patients, confocal endomicroscopy and EUS in 1 patient, and endocytoscopy in another patient. Fourteen patients (56%) had spontaneous stone passage. Eleven patients (44%) had residual gallstones on cholecystoscopy, and removed in 8. Overall stone clearance rate was 88% after a mean (standard deviation) number of 1.25 (0.46) sessions of cholecystoscopy. Per-oral cholecystoscopy and advanced gallbladder interventions were feasible and safe. This opens up exciting possibilities for endoscopic treatment of gallbladder pathologies.