Cholecystostomy Research Articles

S2830 EUS-Guided Cholecystoduodenostomy Gallbladder Mass Biopsy via AXIOS™ Stent

Introduction: Gallbladder carcinoma (GBC) is a rare malignancy with an incidence rate of 2-4 people per 100,000 with a 5% five-year survival rate.1 Imaging modalities typically used to diagnose GBC are Magnetic Resonance Imaging (MRI), Computed Tomography (CT), and Magnetic resonance cholangiopancreatography (MRCP). However, an emerging diagnostic technique is Endoscopic Ultrasound (EUS) which has a more favorable sensitivity at 92-97%.2 Following imaging diagnostics, either surgery or tissue biopsy is sought. Ultrasound-guided fine-needle aspiration (FNA) and Endoscopic retrograde cholangiopancreatography (ERCP) have been used as modalities for achieving a biopsy.3 EUS-guided cholecystoduodenostomy (EUS-CDS) has emerged as a new alternative in high-risk patients. This procedure involves using endoscopic ultrasound to identify an area where the AXIOS delivery catheter can be inserted to deploy a stent. We present the case of an 89-year-old male who underwent a trans-AXIOS stent gallbladder mass biopsy during EUS-CDS. Case Description/Methods: An 89-year-old male with a past medical history of coronary artery disease, heart failure with reduced ejection fraction, and atrial fibrillation was admitted for cholecystitis. Interventional radiology (IR) was consulted to place a percutaneous cholecystostomy tube. Outside hospital records had reported concern for gallbladder malignancy. Gastroenterology (GI) was then consulted and recommended further workup with MRCP. This showed multiple lesions within the gallbladder. Contrast-enhanced ultrasound was then done, which showed the enhancement of 3 polypoid lesions within the gallbladder lumen shown in Figure a. EUS-CDS was then done via the AXIOS stent, which demonstrated multiple masses within the lumen. Finally, multiple biopsies of the masses shown in Figure b were taken. Subsequent pathology (Figures 1c and 1d) is shown.The patient was later seen by surgery; however, he was not a surgical candidate. Instead, he was seen by oncology and was placed on Gemcitabine-Cisplatin therapy. Discussion: GBC is primarily found in the later stages of its course, and when found preoperatively, only 15-47% are suitable for resection.4 This case presents a unique way in which a high-risk individual was able to undergo a biopsy. It will be essential to consider EUS-CDS as means to not only perform gallbladder drainage but also for tissue diagnosis. As this is an emerging technique, it is vital to contribute cases and experiences to the literature for further investigations.Figure 1.: a) shows one of the three intraluminal gallbladder polyps (white arrow). Largest Measuring 2.7cm. b) is the endoscopic picture of the friable necrotic appearing mass proceeding multiple biopsies (white arrow). c) shows WT 10X dysplasia = 100X magnification of background dysplasia – left side of the tissue demonstrate inflamed no neoplastic epithelium with basally oriented nuclei, compared to high-grade dysplasia with loss of nuclear polarity, nuclear atypia, and enlarged hyperchromatic nuclei. d) shows WT 20X adenocarcinoma = 200X magnification- cohesive aggregate of neoplastic glandular cells with surface ulceration and luminal necrotic debris.

S2835 Gastro-Cholecysto-Colonic Fistula Following Endoscopic Ultrasound-Guided Gallbladder Drainage for Stump Cholecystitis: A Case Report

Introduction: Cholecystocolonic fistulas (CCF) usually occur as a complication of gallstones but cases due to malignancy, peptic ulcers, and Crohn’s disease have been reported. We present a case of a gastro-cholecysto-colonic fistula after endoscopic ultrasound guided-gallbladder drainage (EUS-GBD) for stump cholecystitis. Case Description/Methods: A 50 year old male presented with abdominal pain. CT scan noted acute cholecystitis. He underwent laparoscopic converted to open subtotal cholecystectomy due to significant inflammation around the gallbladder. He represented 3 weeks later for abdominal pain. CT showed stump cholecystitis. Gastroenterology was consulted for EUS-GBD given his poor surgical candidacy. Diagnostic EUS revealed choledocholithiasis. Endoscopic retrograde cholangiography (ERC) with cholangioscopy, electrohydraulic lithotripsy, and stone removal was completed. Transgastric EUS-GBD with a 10 x 10 mm electrocautery enhanced lumen apposing metal stent (LAMS) was then performed followed by double pigtail stent (DPT) placement within the LAMS. At a follow up visit, abdominal pain resolved but he developed debilitating diarrhea and was started on cholestyramine. Upper endoscopy 4 weeks after EUS-GBD revealed a gastro-cholecysto-colonic fistula with the proximal end of the DPT in the colon. Cholecystoscopy confirmed absence of gallstones so the LAMS and DPT were removed. Clips were used to close the cholecystogastric tract. Oral contrasted CT with delayed images showed tethering of the gallbladder to the hepatic flexure but no extravasation of contrast into the gallbladder from either the stomach or colon. Given this, clinical observation was pursued. Six weeks later, CT noted similar tethering without contrast leak. On colonoscopy, an area of inflamed mucosa at the hepatic flexure was seen without a patent fistula tract. Biopsies showed chronic colitis. Diarrhea subsequently resolved. (Figure) Discussion: CCFs are a rare complication of gallstone disease. If untreated, biliary sepsis can occur. Surgery is the standard treatment but endoscopic transpapillary gallbladder drainage with a DPT can promote fistula healing in non-surgical patients. We present a case of a gastro-cholecysto-colonic fistula in a poor surgical candidate after EUS-GBD for stump cholecystitis. This was managed with closure of the cholecystogastric tract. CCF closure occurred spontaneously. In cases of persistent CCF, transpapillary gallbladder drainage should be considered.Figure 1.: A. Double pigtail stent migrated into transverse colon with gastro-cholecysto-colonic fistula as viewed from the gallbladder lumen. B. CT scan showing tethering of hepatic flexure to remnant gallbladder (red arrow) without contrast extravasation into the gallbladder from the stomach or colon. C. Closed cholecystocolonic fistula (black arrow) viewed from the hepatic flexure.

S1143 Endoscopic Retrograde Cholangiopancreatography-Guided Gallbladder Drainage Is a Better Alternative to Percutaneous Cholecystostomy as Bridging Therapy to Cholecystectomy in Acute Cholecystitis

S1143 Endoscopic Retrograde Cholangiopancreatography-Guided Gallbladder Drainage Is a Better Alternative to Percutaneous Cholecystostomy as Bridging Therapy to Cholecystectomy in Acute Cholecystitis

S1130 Safety and Efficacy of Endoscopic Ultrasound-Guided Gallbladder Drainage Performed by Early Career Advanced Endoscopists: A Multicenter Experience

S1130 Safety and Efficacy of Endoscopic Ultrasound-Guided Gallbladder Drainage Performed by Early Career Advanced Endoscopists: A Multicenter Experience

S1092 Outcomes of Endoscopic Ultrasound-Guided Gallbladder Drainage in Malignant Biliary Obstruction: A Meta-Analysis

S1092 Outcomes of Endoscopic Ultrasound-Guided Gallbladder Drainage in Malignant Biliary Obstruction: A Meta-Analysis

Contralateral gallbladder perforation and hemoperitoneum caused by an electrocautery-enhanced lumen-apposing metal stent during endoscopic ultrasound-guided gallbladder drainage.

Contralateral gallbladder perforation and hemoperitoneum caused by an electrocautery-enhanced lumen-apposing metal stent during endoscopic ultrasound-guided gallbladder drainage.

Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography and transpapillary gallbladder drainage

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Clinical outcomes and predictors of technical failure of endoscopic transpapillary gallbladder drainage in acute cholecystitis

Background and aims Endoscopic transpapillary gallbladder drainage (ETGBD) has been performed as an alternative therapy against cholecystectomy in patients with acute cholecystitis. To date, few studies have reported the safety, efficacy, and factors affecting ETGBD. We evaluated the clinical outcomes and predictors of technical failure of ETGBD. Methods Patients with acute cholecystitis who underwent ETGBD were retrospectively reviewed, and consecutive patients were included in the study. The technical success rate, clinical success rate, adverse events, and the predictors associated with the technical failure of ETGBD were investigated. Results A total of 242 patients were enrolled in the study. The technical success rate of ETGBD and clinical success rate of technically successful ETGBD cases were 87% and 93%, respectively. We experienced cystic duct injury in 24 patients as an ETGBD-related adverse event, and pancreatitis in 12 patients as an endoscopic retrograde cholangiopancreatography-related adverse event. Multivariate analysis indicated that cystic duct injury was the independent predictor associated with the technical failure of ETGBD (odds ratio, 11; 95% confidence interval, 3.9–29; p < 0.001). Conclusions ETGBD was a safe and effective treatment method for acute cholecystitis with acceptable adverse events. There was no predictor based on the information from patient characteristics; however, cystic duct injury was associated with the technical failure of ETGBD.

Efficacy of an easy loop-forming guidewire in endoscopic transpapillary gallbladder drainage with gallstones impacted in the cystic duct.

Endoscopic transpapillary gallbladder drainage (ETGBD) is a drainage method for acute cholecystitis; it is often used in patients who are on antithrombotic drugs or in those presenting with ascites [1] [2] [3]. However, the success rate of the procedure is lower than that of percutaneous transhepatic biliary drainage (PTGBD), and one of the reasons for this is the difficulty of inserting the guidewire into the gallbladder [4]. Especially in cases where a stone is impacted in the cystic duct, it becomes even more difficult to insert the guidewire into the gallbladder [5].A 75-year-old man with acute cholecystitis had been referred because of septic shock. The patient was taking two antithrombotic drugs. Computed tomography revealed gallbladder wall thickening, gallstones, and fat-stranding around the enlarged gallbladder ([Fig. 1]). Magnetic resonance cholangiopancreatography confirmed the presence of impacted gallstones in the cystic duct ([Fig. 2]). Because of the antithrombotic drugs and the presence of ascites, ETGBD was selected as the drainage method.

Ultrasound-Guided Percutaneous Transhepatic Gallbladder Drainage Improves the Prognosis of Patients with Severe Acute Cholecystitis.

The aim of this study was to investigate the clinical efficacy of ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) for the treatment of severe acute cholecystitis (AC). The data of 40 patients diagnosed with severe AC at our hospital between August 2020 and June 2021 were retrieved and classified into a PTGD group, open cholecystostomy (OC) group, laparoscopic cholecystectomy (LC) group, and conventional conservative treatment (CT) group. Before treatment and on days 1, 3, 5, and 7 after treatment, their serum levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP), aspartate aminotransferase (AST), total bilirubin (TBIL), triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), white blood cell count (WBC), IL-2, IL-4, IL-6, IL-8, and cancer antigen 19–9 (CA19-9) were measured. Additionally, clinical manifestations such as body temperature and pain score were monitored before treatment and at 24, 48, and 72 hours after treatment. The recovery time and complications/adverse reactions were statistically analyzed, and the Kaplan–Meier survival curve was plotted. After treatment, compared with the other three groups, the PTGD group had a significant reduction in serum indicators, including WBC and inflammatory factors, recovery time, pain score, and complications, and benefitted from better treatment efficacy and higher survival rate. Thus, ultrasound-guided PTGD was found to be more effective in treating severe AC patients and was associated with improved patient prognoses.

National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society.

Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS). An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences. For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation). Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed. The Danish Surgical Society.

Gel immersion-assisted endoscopic ultrasound-guided gallbladder drainage using a fine-gauge electrocautery dilator.

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Successful minimally invasive management of adverse events following EUS-guided gallbladder drainage in a suboptimal surgical patient.

Video 1Successful minimally invasive management of adverse events following EUS-guided gallbladder drainage in a suboptimal surgical patient.

EP-221 Outcome of early cholecystectomy compared to percutaneous drainage of gallbladder and delayed cholecystectomy for patients with acute cholecystitis: systematic review and meta-analysis

Abstract Aim Compare outcomes of ELC and PTGBD as an initial intervention for AC and to compare operative outcomes of ELC and delayed laparoscopic cholecystectomy (DLC). Methods English-language studies published until December 2020 were searched. Randomised controlled trials (RCTs) and observational studies compared EC and PTGBD with delayed cholecystectomy for patients presented with acute cholecystitis were considered. Main outcomes were mortality, conversion to open, complications and length of hospital stay. Results Out from 1347 records,14 studies were included. 205,361(94.7%) patients had EC and 11,565 (5.3%) patients had PTGBD as an initial intervention for AC. Risk of mortality was considerably higher in PTGBD compared to EC group; HR,95% CI: [3.68 (2.13, 6.38)]. In contrast, complication rate was significantly higher in EC group (47%) vs 8.7% in PTGBD group in patients admitted to ICU for sepsis related to AC; P-value=0.011. ELC group had more intra-operative blood loss than DLC group; MD (95%CI): 34.2 (4.15, 64.25) ml. There was no difference in mortality between the two groups; HR (95% CI): 1.30 [0.60, 2.83] Patients had ELC are at higher risk of post-operative complications compared to DLC; RR [95% CI]: 2.88 [1.78, 4.65]. Risk of bile leak or bile duct injury was six folds more in ELC; RR [95% CI]: 6.07 [1.67, 21.99]. Conclusion ELC should be considered for all patients with acceptable surgical risk admitted with AC regardless its severity. PTGBD can be considered for patients admitted to the ICU for organ support. Future studies needed to assess the validity of this approach.

Impact of endoscopic ultrasound-guided gallbladder drainage on reducing costs of reintervention and unplanned readmission: a budget impact analysis.

Background and study aims Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is the preferred treatment for patients with acute calculous cholecystitis who are unfit for surgery. The aim of this study was to perform a cost-effective analysis (CEA) comparing EUS-GBD with percutaneous gallbladder drainage (PT-GBD). Patients and methods CEA was performed on patients recruited for our prior randomized controlled trial. A budget impact model was developed to compare the base-case and scenario of EUS-GBD applications. The costs including peri-procedure and intra-procedure, reinterventions, expenses associated with treatment of adverse events (AEs), costs of hospital stay, subsequent clinic follow-up, and unplanned readmission were included. Results PT-GBD had a lower total procedure cost per patient (USD$4,375.00) than EUS-GBD (USD$9,397.44). For EUS-GBD, the cost of cautery-enhanced lumen-apposing stent accounted for the major part of the expense (USD$4,910.26). EUS-GBD resulted in a lower expected cost (USD$108.26 vs USD$1,601.54) for a re-procedure. The expected cost per patient in unplanned readmissions in the EUS-GBD group (USD$450.00) was lower than that in the PT-GBD group (USD$1,717.56). Based on the budget impact analysis, the net budget impact per year of introducing EUS-GBD to replace PT-GBD was higher (USD$16,424.10 vs USD$11,433.08). The net budget impact was most sensitive to the cost of stent and linear echoendoscope used in EUS-GBD. Conclusions The net budget impact per year was higher for introducing EUS-GBD. The cost of the stent accounted for the major cost difference between the two procedures. EUS-GBD saved on the cost in management of AEs, reinterventions, and unplanned readmissions but these did not offset the cost of the stent.

Radiation exposure during modern therapeutic endoscopic ultrasound procedures and standard alternatives.

Background and study aims Therapeutic EUS (t-EUS) is increasingly being adopted in clinical practice in tertiary referral centers; however, little is known about radiation exposure (RE) metrics and diagnostic reference limits for it. Methods Kerma-area product (KAP [Gy·cm 2 ]), Air Kerma and fluoroscopy time were retrospectively evaluated for all consecutive t-EUS procedures performed in San Raffaele Institute between 2019 and 2021. For EUS-guided choledochoduodenostomies (EUS-CDS) and gastroenterostomies (EUS-GE), an equal number of endoscopic retrograde cholangiopancreatographies (ERCPs) plus metal stenting and duodenal stents were included respectively for comparison. Results Data from 141 t-EUS procedures were retrieved (49 % pancreatic cancer, 38 % peripancreatic fluid collections). EUS-CDS (N = 44) were mainly performed fluoroless, while ERCPs required a significantly higher RE (KAP = 25 [17–55], P < 0.0001). Fluid collection drainage (EUS-FCD) with lumen apposing metal stents (LAMS, N = 26) were performed fluoroless, while EUS-FCD with double-pigtail plastic stents (DPPS, N = 28) required higher RE (KAP = 23 [13–45]). EUS-guided gallbladder drainage (EUS-GBD, N = 6) required scarce RE (KAP = 9 [3–21]) for coaxial DPPS placement. EUS-GE (N = 27) required higher RE than duodenal stenting (KAP = 44 [28–88] versus 29 [19–46], P = 0.03). EUS-guided hepaticogastrostomies (EUS-HGS, N = 10) had the highest RE among t-EUS procedures (KAP = 81 [49–123]). Procedure complexity or intervening complications were evaluated and resulted in higher RE within each procedure. Conclusions t-EUS procedures have different RE ( P < 0.000001). EUS-CDS, EUS-GBD, and EUS-FCD with LAMS can be performed with no-to-mild radioscopy, unlike standard alternatives. However, radioscopy remains essential in case of technical difficulties or complications. EUS-GE and EUS-HGS involve a high RE. Endoscopists involved in t-EUS might experience RE higher than category standards, which indicates a need for increased awareness and personalized preventive measures.

Successful re-intervention of endoscopic ultrasound-guided gallbladder drainage using a dual-channel endoscope.

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Endoscopic ultrasound guided biliary drainage: literature review

Mantas Markauskas1 1Vilnius City Clinical Hospital, Vilnius, Lithuania Abstract Background. The first echoendoscope was introduced only as diagnostic tool in 1980 and it was mainly used to diagnose tumors, located in mediastinum, pancreas, liver or biliary tree. Therapeutic procedures using endoscopic ultrasound became possible only in 1991, when first linear echoendoscope and needle compatible with it were introduced. During past two decades echoendoscope and its accessories were improved, therefore complex therapeutic procedures using endoscopic ultrasound, such as gallbladder and biliary drainage, pancreatic duct and peripancreatic fluid drainage, pancreatic tumor ablation, brachytherapy, celiac plexus neurolysis, gastroenterostomy and many others, became possible. Aim. To discuss the recent literature describing endoscopic ultrasound guided biliary drainage. Procedure is discussed in terms of its indications, technique, results and adverse events. Methods. The literature search was performed in the PubMed database by entering relevant keywords in various combinations into the regular and advanced search fields, as well as using the bibliographies of the articles found. A total of 38 publications were found during the review, with 24 scientific publications based on the inclusion criteria. Conclusion. Literature indicates that endoscopic ultrasound guided biliary drainage can be safely performed on patients with biliary obstruction after failed endoscopic retrograde cholangiopancreatography. Present studies allow to conclude that endoscopic ultrasound guided biliary drainage is safe and efficient. However, in order to confirm endoscopic ultrasound guided biliary drainage as first-line treatment on patients with biliary obstruction after failed endoscopic retrograde cholangiopancreatography, further large prospective multicenter studies are needed. Keywords: endoscopic ultrasound, therapeutic procedures, biliary drainage.

Analysis of the Effect of Laparoscopic Cholecystectomy for Acute Cholecystitis after Percutaneous Transhepatic Gallbladder Puncture and Drainage.

Objective To assess the effect of laparoscopic cholecystectomy for acute cholecystitis after percutaneous transhepatic gallbladder drainage (PTGBD). Methods A total of 70 patients with acute cholecystitis diagnosed and treated in our hospital between April 2020 and November 2021 were recruited and assigned to receive either conventional treatment (conventional group) or PTGBD plus laparoscopic cholecystectomy (experimental group) according to the order of admission (with January 2021 as the cut-off time point), with 35 cases in each group. Outcome measures included treatment outcomes, surgical indices, and postoperative recovery. Results Patients in the experimental group showed significantly less intraoperative hemorrhage volume and shorter operative time, time-lapse before passing gas, and hospital stay (83.15 ± 31.17, 32.54 ± 12.61, 23.02 ± 4.61, 7.98 ± 3.24) versus those in the conventional group (120.56 ± 30.55, 61.01 ± 15.54, 28.15 ± 5.91, 11.95 ± 4.15) (P < 0.05). The incidence of conversion to open surgery and postoperative drainage in the experimental group was significantly lower (2.86%, 5.71%) than that of the conventional group (25.71%, 45.71%) (P < 0.05). The differences in the postoperative body temperature of the two groups did not come up to statistical standard (P > 0.05). The experimental group had faster body temperature recovery and leukocyte recovery and better leukocyte levels (1.25 ± 0.56, 2.36 ± 0.48, 7.92 ± 1.36) than the conventional group (3.11 ± 1.05, 5.41 ± 0.63, 10.52 ± 2.78) (P < 0.05). There was 1 (2.86%) case of pneumothorax and 1 (2.86%) case of intestinal bleeding in the experimental group, and there were 2 (5.71%) cases of biliary leakage, 3 (8.57%) cases of pneumothorax, 4 (11.43%) cases of intestinal bleeding, 5.71% cases of incisional infection, 1 (2.86%) case of respiratory failure, and 1 (2.86%) case of liver damage in the conventional group. The experimental group showed a significantly lower incidence of complications (5.71%) versus the conventional group (37.14%) (P < 0.05). Conclusion PTGBD plus laparoscopic cholecystectomy for acute cholecystitis effectively improves surgical safety, promotes patients' postoperative recovery, and reduces the incidence of conversion to open surgery and postoperative complications with a high safety profile. Further trials are, however, required prior to clinical promotion.

"Rescue" rendezvous technique during endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis.

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