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Original article Clinical endoscopy: Editorial| Volume 82, ISSUE 6, P1037-1038, December 2015

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Nonsurgical management of cholecystitis: a tailored approach

      The management of symptomatic gallbladder disease has evolved considerably over the past 150 years. Surgical cholecystostomy was performed in 1867 for the treatment of symptomatic gallbladder disease.
      • Sparkman R.S.
      The early development of gall-bladder surgery. Centennial of the proposed cholecystostomy of J. L. W.
      A massively hydropic gallbladder was opened, a large amount of fluid and stones removed, and the gallbladder closed and left in situ. Surgical resection of the gallbladder—open cholecystectomy—was subsequently performed in 1882.
      • Sparkman R.S.
      The early development of gall-bladder surgery. Centennial of the proposed cholecystostomy of J. L. W.
      Open cholecystectomy was essentially the only invasive treatment performed for nearly 100 years until the introduction of percutaneous cholecystostomy in 1980.
      • Radder R.W.
      Ultrasonically guided percutaneous catheter drainage for gallbladder empyema.
      Endoscopic transpapillary gallbladder drainage at the time of ERCP, although proposed in 1984, was first reported in 1990.
      • Feretis C.B.
      • Manouras A.J.
      • Apostolidis N.S.
      • et al.
      Endoscopic transpapillary drainage of gallbladder empyema.
      Most recently, EUS-guided transmural gallbladder drainage was first described in 2007.
      • Baron T.H.
      • Topazian M.D.
      Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease.
      Although laparoscopic cholecystectomy remains the criterion standard for management of calculous cholecystitis in patients who can safely undergo early surgery, elderly patients with severe comorbid medical illnesses, patients with severe calculous cholecystitis, and those with acalculous cholecystitis are often best treated with temporary or definitive nonsurgical interventions.
      With the myriad nonsurgical interventions and approaches to cholecystitis, which is the best approach? In an attempt to answer this question, Kedia et al,
      • Kedia P.
      • Sharaiha R.Z.
      • Kumta N.A.
      • et al.
      Endoscopic gallbladder drainage compared with percutaneous drainage.
      in this issue of Gastrointestinal Endoscopy, report a retrospective review of the outcomes of patients with both calculous and acalculous cholecystitis who were deemed not to be fit for surgery and instead underwent percutaneous and endoscopic (transpapillary or transmural) drainage in a tertiary medical center. From 2011 to 2013, 73 patients were treated: 43 with percutaneous drainage and 30 with endoscopic drainage (24 transpapillary, 6 transmurally). No differences were seen in technical success or in clinically successful resolution of acute cholecystitis. However, statistically significant differences in favor of the endoscopically treated patients were seen in time to resolution of cholecystitis, need for reintervention, mean pain scores, adverse events, and hospital length of stay.
      The results of this study mirror what we have seen in other disease states, where percutaneous therapy was the modality introduced initially but was subsequently superseded by endoscopic therapy, as in treatment of acute cholangitis due to choledocholithiasis, and palliation of extrahepatic biliary obstruction. The message is the same: internal drainage trumps external drainage in many important aspects, not the least of which is patient comfort.
      Does this mean that all patients with cholecystitis (dare we say symptomatic cholelithiasis?) who cannot readily undergo cholecystectomy are best treated endoscopically? The answer is a resounding no, not yet.
      First, the results reported are from an academic center with a high level of endoscopic expertise. Percutaneous cholecystostomy tube placement is readily available in most centers in the United States. Conversely, even in most centers where ERCP and EUS services are offered, gallbladder drainage is often not performed. Transpapillary gallbladder drainage is technically difficult because of the challenge of visualizing and selectively accessing, then traversing, the long, narrow, and tortuous cystic duct, which may also be completely obstructed by stone(s).
      • Itoi T.
      • Coelho-Prabhu N.
      • Baron T.H.
      Endoscopic gallbladder drainage for management of acute cholecystitis.
      EUS-transmural therapy is still considered a high-risk procedure and can also be technically difficult to perform. Bile leakage from unsuccessful stent placement may be a life-threatening event. However, with the advent of new Food and Drug Association (FDA)-approved lumen apposing self-expandable metal stents
      • de la Serna-Higuera C.
      • Pérez-Miranda M.
      • Gil-Simón P.
      • et al.
      EUS-guided transenteric gallbladder drainage with a new fistula-forming, lumen-apposing metal stent.
      and likely to be FDA-approved one-step electrocautery delivery systems,
      • Teoh A.Y.
      • Binmoeller K.F.
      • Lau J.Y.
      Single-step EUS-guided puncture and delivery of a lumen-apposing stent for gallbladder drainage using a novel cautery-tipped stent delivery system.
      EUS-guided transmural drainage will most certainly become much easier and safer, and broadly embraced (with the understanding that FDA approval of such devices for gallbladder drainage is not expected for some time).
      Second, transmural gallbladder drainage with the use of large-bore stents, especially expandable metal stents, should be reserved for patients who absolutely will not undergo subsequent laparoscopic cholecystectomy because the fistula from the duodenum or stomach is likely to be problematic inasmuch as it creates a hole that needs to be closed and adheres the stomach or duodenum to the gallbladder, making dissection difficult. Indeed, this note of caution can be extended to a patient who may later undergo liver transplantation. Although we have reported transmural drainage using a lumen-apposing stent in this setting,
      • Baron T.H.
      • Zacks S.
      • Grimm I.S.
      Endoscopic ultrasound-guided cholecystoduodenostomy for acute cholecystitis in a patient with thrombocytopenia and end-stage liver disease awaiting transplantation.
      the cholecystoduodenal fistula made subsequent liver transplantation technically difficult, and despite surgical closure of the duodenal fistula a postsurgical leak from that site developed and resulted in the formation of an intra-abdominal abscess (in press). Thus, if endoscopic gallbladder drainage is undertaken in patients who may undergo subsequent cholecystectomy or liver transplantation, a transpapillary approach should be used, if possible.
      Third, cholecystitis is really a spectrum of disease states ranging from acute (calculous and acalculous), with possible gallbladder perforation and necrosis, to chronic fibrotic disease. It is not known whether endoscopic therapy is applicable to all grades of severity and chronicity of cholecystitis. Transmural drainage may not be possible when the gallbladder is severely contracted. And neither transpapillary nor transmural endoscopic drainage approaches may be feasible in patients with surgically altered anatomy (eg, gastric bypass). In these cases, percutaneous drainage is the preferred nonoperative drainage strategy.
      We believe that transmural drainage will become the preferred strategy for most patients with symptomatic gallbladder disease who are poor surgical candidates, excluding the caveats mentioned above. However, prospective trials with larger numbers of patients are needed to demonstrate long-term safety and efficacy as compared with percutaneous therapy to determine the best strategy. Preliminary data
      • Walter D.
      • Teoh A.Y.
      • Itoi T.
      • et al.
      EUS-guided drainage with a large diameter metal stent is a safe treatment for acute cholecystitis in high-risk surgical patients.
      from an ongoing prospective trial

      EUS-guided gallbladder drainage with the AXIOS stent in patients with acute cholecystitis unsuitable for surgery: a feasibility study. Available at: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3633. Accessed March 31, 2015.

      in which lumen-apposing stents were used as definitive therapy for acute calculous cholecystitis in high-risk surgical candidates showed promising results. Until similar and larger studies are completed, the approach to a patient with symptomatic gallbladder disease who is a poor operative candidate will likely be based on the preferences of the referring physician, the available resources, and local expertise. When all nonoperative modalities are readily available in a given center, the choice of whether to use one of the two endoscopic approaches or a percutaneous approach should be individualized to the patient based on gastrointestinal and hepatobiliary anatomy, extent of gallbladder disease, and underlying disease processes (cirrhosis, ascites). These nonsurgical approaches should be considered complementary; the sequential application of more than one of these techniques is sometimes the best solution.

      Disclosure

      Dr Baron is a consultant and speaker for Boston Scientific, Cook Endoscopy, W. L. Gore, ConMed, and Olympus. Dr Grimm is a consultant for Boston Scientific.

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