Advertisement
Original article Clinical endoscopy: Editorial| Volume 94, ISSUE 4, P749-751, October 2021

Download started.

Ok

Endoscopic treatment of acute cholecystitis: Can transpapillary stent placement silence the LAMS?

Published:August 13, 2021DOI:https://doi.org/10.1016/j.gie.2021.07.003

      Abbreviation:

      LAMS (lumen-apposing metal stent)
      The development of acute cholecystitis has traditionally required surgical therapy, with percutaneous drainage by interventional radiologists reserved for patients deemed to be nonsurgical candidates. In this issue of Gastrointestinal Endoscopy, Storm et al
      • Storm A.C.
      • Vargas E.J.
      • Chin J.Y.
      • et al.
      Transpapillary gallbladder stent placement for long-term therapy of acute cholecystitis.
      add to the growing literature by, and experience of, endoscopists in the management of inflammatory gallbladder disease. They report on an observational cohort of 51 patients with acute cholecystitis treated over 11 years at a single institution with a mean follow-up time of a little over a year. Importantly, this experience involved only the use of transpapillary gallbladder drainage with standard ERCP techniques and devices, rather than by EUS-guided transmural drainage with lumen-apposing metal stents (LAMSs), which is currently in vogue.
      Patients were selected for endoscopic therapy because of their unsuitability for cholecystectomy related to comorbidities that included poor functional status, malignancy, advanced cardiopulmonary disease, or cirrhosis. Most patients had mild or moderate cholecystitis, although 8 patients had severe cholecystitis (Tokyo grade III). Although the study excluded patients who ultimately underwent cholecystectomy, the authors did not specifically mention exclusion criteria related to the severity of cholecystitis (presumably gangrenous cholecystitis or unconfined perforated cholecystitis were treated operatively without consideration of endoscopic therapy). Importantly, this selected cohort offers specific insight into the natural history of patients with cholecystitis treated endoscopically without a “destination” to cholecystectomy. The authors report an impressive 96% technical and clinical success rate along with a very low rate of recurrence or need for reintervention. This rate of technical and clinical success is higher than those in many prior published experiences that ranged from 75% to 90%,
      • Mohan B.P.
      • Khan S.R.
      • Trakroo S.
      • et al.
      Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis.
      • Widmer J.
      • Alvarez P.
      • Sharaiha R.Z.
      • et al.
      Endoscopic gallbladder drainage for acute cholecystitis.
      • Itoi T.
      • Coelho-Prabhu N.
      • Baron T.H.
      Endoscopic gallbladder drainage for management of acute cholecystitis.
      • Higa J.T.
      • Sahar N.
      • Kozarek R.A.
      • et al.
      EUS-guided gallbladder drainage with a lumen-apposing metal stent versus endoscopic transpapillary gallbladder drainage for the treatment of acute cholecystitis (with videos).
      despite no use of cholangioscopy in this series. In addition, the adverse event rate was modest, at 5.9% (2 post-ERCP pancreatitis and 1 presumed postsphincterotomy bleed).
      In addition to affirming the feasibility and clinical utility of this approach, the authors provide important technical insights regarding the approach to transpapillary gallbladder drainage. Namely, they routinely attempted placement of 2 parallel 7F double-pigtail stents. When this was not feasible, such as in the setting of a small-caliber cystic duct, they planned for a repeated ERCP with upsizing from single to double 7F stents approximately 1 to 2 months after the index procedure. Their experience suggests that this strategy pays off: long-term success was higher in those with double stents (100%) versus only a single stent (89%). Furthermore, all 3 patients who had their transpapillary stents removed experienced recurrent cholecystitis requiring repeated intervention, confirming the common wisdom that patients with cholecystitis without some kind of durable drainage therapy are at high risk of recurrent cholecystitis. Finally, although their technical success rates were very high, this success appears to require persistence and comes with the price of added procedural time and increased radiation exposure, because the mean fluoroscopy time was 25 minutes.
      As endoscopists we are gaining confidence in our ability to manage gallbladder disease. Traditionally, our role in gallstone/gallbladder disease has been limited to clearing the common duct before cholecystectomy and managing the occasional cystic duct stump leak postoperatively. A growing experience with transpapillary and transmural gallbladder drainage has challenged this limited paradigm. Initial experience from 10 to 20 years ago reported favorable outcomes of transpapillary drainage in patients unfit for cholecystectomy or percutaneous drainage.
      • Itoi T.
      • Coelho-Prabhu N.
      • Baron T.H.
      Endoscopic gallbladder drainage for management of acute cholecystitis.
      In our institution, this approach was most often considered for cirrhotic patients with an elevated risk of decompensation with cholecystectomy and adverse events with percutaneous drainage resulting from ascites. However, despite these capabilities and advantages, endoscopic management of gallbladder disease remained somewhat dormant until the description of transmural gallbladder drainage (currently an off-label indication for LAMSs) as part of the growing field of interventional EUS.
      • Kahaleh M.
      • Wang P.
      • Shami V.M.
      • et al.
      Drainage of gallbladder fossa fluid collections with endoprosthesis placement under endoscopic ultrasound guidance: a preliminary report of two cases.
      With increasing comfort with, and interest in, routinely considering endoscopic gallbladder drainage, several important questions arise. When should we consider transpapillary drainage instead of transmural drainage? Should LAMSs be reserved only for patients in whom transpapillary drainage fails? When should percutaneous drainage be performed in lieu of an endoscopic approach? The authors demonstrated an impressive rate of technical success, but this may not be reproducible in less experienced or less persistent hands. There had been (and perhaps continues to be) a parallel LAMS versus plastic stent discussion regarding pancreas pseudocyst management. Specifically, despite the elegance and novelty of the EUS-guided LAMS placement, the initial enthusiasm was tempered by concerns regarding higher rates of postprocedural bleeding (along with the substantially higher cost) associated with LAMS use.
      • Brimhall B.
      • Han S.
      • Tatman P.D.
      • et al.
      Increased incidence of pseudoaneurysm bleeding with lumen-apposing metal stents compared to double-pigtail plastic stents in patients with peripancreatic fluid collections.
      If cystic duct stent placement can be so successful, when or why should transmural LAMSs even be considered? Should procedural time factor into decision making? As noted above, although these transpapillary procedures were very successful, they were not short: the mean fluoroscopy time was reported as 25 minutes. The authors acknowledge this represents a longer fluoroscopy time compared with typical ERCP and probably is a surrogate marker for a much longer total procedural time resulting from the difficulty in deeply cannulating and stenting the cystic duct and gallbladder. An endoscopist with experience in EUS-guided gallbladder drainage could argue that a LAMS could be deployed in substantially less time with less (or no) radiation exposure to the patient and staff. Although the procedural time for transpapillary drainage might be shortened with a more liberal use of cholangioscopy, this would significantly reduce the cost savings of this approach compared with EUS-guided gallbladder drainage with the use of LAMSs.
      As we develop endoscopic techniques and patient selection is refined, where does the role of percutaneous drainage fit? A growing body of literature suggests that endoscopic gallbladder drainage is as safe and effective as percutaneous drainage, with less need for reintervention or readmission.
      • Mohan B.P.
      • Khan S.R.
      • Trakroo S.
      • et al.
      Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis.
      ,
      • Higa J.T.
      • Sahar N.
      • Kozarek R.A.
      • et al.
      EUS-guided gallbladder drainage with a lumen-apposing metal stent versus endoscopic transpapillary gallbladder drainage for the treatment of acute cholecystitis (with videos).
      ,
      • Krishnamoorthi R.
      • Jayaraj M.
      • Chandrasekar V.T.
      • et al.
      EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.
      ,
      • Podboy A.
      • Yuan J.
      • Stave C.D.
      • et al.
      Comparison of EUS-guided endoscopic transpapillary and percutaneous gallbladder drainage for acute cholecystitis: a systematic review with network meta-analysis.
      Although the need for percutaneous drainage is unlikely to be eliminated, how do we determine who is better suited to which method (or ill suited for another)? Along these same lines, how exactly do we decide who is a poor operative candidate, given this growing number of nonoperative treatment options? Depending on the institution, ERCP is often performed with the patient under general anesthesia with endotracheal intubation. Are patients who are thought to be poor operative candidates because of cardiopulmonary comorbidities significantly safer with endoscopy under general anesthesia versus laparoscopy? These are nuanced and as yet unanswered questions.
      In patients for whom a subsequent cholecystectomy is planned, transpapillary drainage may be preferable to transmural drainage. Although it should be noted that there is experience with cholecystectomy after LAMS placement,
      • Saumoy M.
      • Tyberg A.
      • Brown E.
      • et al.
      Successful cholecystectomy after endoscopic ultrasound gallbladder drainage compared with percutaneous cholecystostomy, can it be done?.
      most surgeons are unfamiliar with—and may be reluctant to adopt—this approach. Transpapillary drainage may also be more desirable in patients who are undergoing evaluation for liver transplantation and/or have significant ascites, and these and other special patient populations will need to be considered as new algorithms for managing cholecystitis are developed that account for endoscopic therapies. Notably, the same institution previously reported a favorable experience with the use of transpapillary stent placement as a bridge to cholecystectomy in separate publications.
      • Pannala R.
      • Petersen B.T.
      • Gostout C.J.
      • et al.
      Endoscopic transpapillary gallbladder drainage: 10-year single center experience.
      ,
      • Kaura K.
      • Bazerbachi F.
      • Sawas T.
      • et al.
      Surgical outcomes of ERCP-guided transpapillary gallbladder drainage versus percutaneous cholecystostomy as bridging therapies for acute cholecystitis followed by interval cholecystectomy.
      Cholecystectomy was successfully performed without higher rates of operative adverse events or conversion to open surgery compared with percutaneous cholecystostomy.
      • Kaura K.
      • Bazerbachi F.
      • Sawas T.
      • et al.
      Surgical outcomes of ERCP-guided transpapillary gallbladder drainage versus percutaneous cholecystostomy as bridging therapies for acute cholecystitis followed by interval cholecystectomy.
      As gastroenterologists expand our role in the management of gallbladder disease, understanding the nuances of disease severity so as to appropriately select therapy for patients with cholecystitis will be essential. Familiarity with grading systems of cholecystitis (such as the Tokyo classification, used in this article) will be important. We will need to learn from our surgery colleagues which patients can be medically treated, which can be temporized with drainage procedures, and who will need immediate surgery. Similarly, we will need to gain familiarity in interpreting CT and US imaging with our radiology colleagues to identify signs of perforation or gangrenous cholecystitis and recognize them as unsuitable for endoscopic drainage. Finally, we will need to learn the indications for, and contraindications to, percutaneous gallbladder drainage and adapt those to endoscopic transmural and transpapillary gallbladder drainage. This study on the long-term durability of endoscopic transpapillary stent placement to treat cholecystitis will, it is hoped, become part of a critical mass of evidence that can eventually be used to formulate evidence-based guidelines that can guide endoscopists in defining their role in managing this disease.
      The authors are to be congratulated for adding to the growing experience of gallbladder drainage by endoscopists. They offer good data for a durable and cost-effective endoscopic option for cholecystitis. At the very least, this article suggests that (1) endoscopic transpapillary drainage is safe and feasible, with a high technical success rate if one is willing to dedicate adequate time to traversing the cystic duct; (2) appropriately selected patients can be treated in the short to medium term without a need for cholecystectomy or stent changes; and (3) 2 stents are likely better than 1 stent in minimizing the need for reintervention.
      So, where do we go from here? We are at the dawn of establishing an algorithmic standard to personalize gallbladder drainage. Currently, our involvement as endoscopists most commonly involves assessing and treating patients with known or suspected choledocholithiasis. In the future, it is quite possible that endoscopists will routinely be called to treat selected patients with cholecystitis as well. We therefore propose a robust discussion before ERCP is undertaken about the patient’s candidacy for cholecystectomy (immediately and in the future) so that in all appropriate cases, an attempt at transpapillary drainage in patients deemed unfit for surgery is made. If ERCP is being done anyway, there should at least be consideration of an attempt at cystic duct stent placement, preferably with 2 parallel 7F double-pigtail stents. If ERCP is not being planned (for example, if EUS or MRCP excludes choledocholithiasis reliably), or if reasonable attempts (within a vaguely predetermined procedural time, including cholangioscopy) at cystic duct access are unsuccessful, transmural EUS-guided gallbladder drainage with the use of LAMSs should be offered. With this approach, the consent process should include the possibility of both a transpapillary and a transmural approach.
      At present, it appears that the EUS-guided transmural approach has the better technical and clinical success rates, on the basis of several systematic reviews,
      • Mohan B.P.
      • Khan S.R.
      • Trakroo S.
      • et al.
      Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis.
      ,
      • Krishnamoorthi R.
      • Jayaraj M.
      • Chandrasekar V.T.
      • et al.
      EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.
      ,
      • Podboy A.
      • Yuan J.
      • Stave C.D.
      • et al.
      Comparison of EUS-guided endoscopic transpapillary and percutaneous gallbladder drainage for acute cholecystitis: a systematic review with network meta-analysis.
      but the transpapillary stent placement studies included in these analyses likely did not use the aggressive approach in accessing and dual stenting of the gallbladder demonstrated in this report. To validate an approach to gallbladder drainage that achieves widespread adoption, the ultimate step would be a large prospective, randomized study comparing percutaneous, transmural, and transpapillary drainage in nonoperative candidates with a crossover allowance from transpapillary to transmural drainage at the same session. In the interim, will transpapillary gallbladder drainage “silence” the LAMS? Probably not, but it can and should be an important option in the endoscopic management of gallbladder disease.
      In conclusion, although more precise indications for transpapillary versus transmural gallbladder drainage will be defined in the coming years, we believe the endoscopist’s role in managing cholecystitis is only just beginning and is here to stay.

      Disclosure

      Dr Sedarat is a consultant for Boston Scientific. Dr Muthusamy is a consultant for, and the recipient of research support from, Boston Scientific and Medtronic; a consultant for Medivators and Interpace Diagnostics; the recipient of speaking fees and honoraria from Torax Medical/Ethicon; and a stockholder in Capsovision.

      References

        • Storm A.C.
        • Vargas E.J.
        • Chin J.Y.
        • et al.
        Transpapillary gallbladder stent placement for long-term therapy of acute cholecystitis.
        Gastrointest Endosc. 2021; 94: 742-748. e1
        • Mohan B.P.
        • Khan S.R.
        • Trakroo S.
        • et al.
        Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis.
        Endoscopy. 2020; 52: 96-106
        • Widmer J.
        • Alvarez P.
        • Sharaiha R.Z.
        • et al.
        Endoscopic gallbladder drainage for acute cholecystitis.
        Clin Endosc. 2015; 48: 411-420
        • Itoi T.
        • Coelho-Prabhu N.
        • Baron T.H.
        Endoscopic gallbladder drainage for management of acute cholecystitis.
        Gastrointest Endosc. 2010; 71: 1038-1045
        • Higa J.T.
        • Sahar N.
        • Kozarek R.A.
        • et al.
        EUS-guided gallbladder drainage with a lumen-apposing metal stent versus endoscopic transpapillary gallbladder drainage for the treatment of acute cholecystitis (with videos).
        Gastrointest Endosc. 2019; 90: 483-492
        • Kahaleh M.
        • Wang P.
        • Shami V.M.
        • et al.
        Drainage of gallbladder fossa fluid collections with endoprosthesis placement under endoscopic ultrasound guidance: a preliminary report of two cases.
        Endoscopy. 2005; 37: 393-396
        • Brimhall B.
        • Han S.
        • Tatman P.D.
        • et al.
        Increased incidence of pseudoaneurysm bleeding with lumen-apposing metal stents compared to double-pigtail plastic stents in patients with peripancreatic fluid collections.
        Clin Gastroenterol Hepatol. 2018; 16: 1521-1528
        • Krishnamoorthi R.
        • Jayaraj M.
        • Chandrasekar V.T.
        • et al.
        EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.
        Surg Endosc. 2020; 34: 1904-1913
        • Podboy A.
        • Yuan J.
        • Stave C.D.
        • et al.
        Comparison of EUS-guided endoscopic transpapillary and percutaneous gallbladder drainage for acute cholecystitis: a systematic review with network meta-analysis.
        Gastrointest Endosc. 2021; 93: 797-804.e1
        • Saumoy M.
        • Tyberg A.
        • Brown E.
        • et al.
        Successful cholecystectomy after endoscopic ultrasound gallbladder drainage compared with percutaneous cholecystostomy, can it be done?.
        J Clin Gastroenterol. 2019; 53: 231-235
        • Pannala R.
        • Petersen B.T.
        • Gostout C.J.
        • et al.
        Endoscopic transpapillary gallbladder drainage: 10-year single center experience.
        Minerva Gastroenterol Dietol. 2008; 54: 107-113
        • Kaura K.
        • Bazerbachi F.
        • Sawas T.
        • et al.
        Surgical outcomes of ERCP-guided transpapillary gallbladder drainage versus percutaneous cholecystostomy as bridging therapies for acute cholecystitis followed by interval cholecystectomy.
        HPB (Oxford). 2020; 22: 996-1003

      Linked Article

      • Transpapillary gallbladder stent placement for long-term therapy of acute cholecystitis
        Gastrointestinal EndoscopyVol. 94Issue 4
        • Preview
          Select patients with acute cholecystitis (AC) are poor candidates for cholecystectomy. ERCP-guided transpapillary gallbladder (GB) drainage (ERGD) is one modality for nonoperative management of AC in these patients. Our primary aim was to evaluate long-term success of destination ERGD. Secondary aims were the rate of technical and clinical success, number of repeat procedures, rate of adverse events, and risk factors for recurrent AC.
        • Full-Text
        • PDF