Ann Hepatobiliary Pancreat Surg.  2022 Feb;26(1):104-112. 10.14701/ahbps.21-098.

Ultimate outcomes of three modalities for non-surgical gallbladder drainage in acute cholecystitis with or without concomitant common bile duct stones

• Ridtitid W
• Luangsukrerk T
• Piyachaturawat P
• Teeratorn N
• Angsuwatcharakon P
• Kongkam P
• Rerknimitr R

• KMID: 2526839
• DOI: http://doi.org/10.14701/ahbps.21-098

Abstract

Backgrounds/Aims
In moderate and high-surgical risk patients with acute cholecystitis, studies comparing percutaneous cholecystostomy (PC) vs. endoscopic transpapillary gallbladder stenting (ETGS) vs. endoscopic ultrasound-guided transmural gallbladder stenting (EUGS) are limited. Thus, the aim of this study was to compare efficacy and recurrence of cholecystitis after PC, ETGS, or EUGS during follow-up.
Methods
We reviewed 143 moderate and high-surgical risk patients with acute cholecystitis with or without concomitant common bile duct stones who underwent PC, ETGS, or EUGS at our hospital. Technical success rate (TSR), clinical success rate (CSR), and recurrence were compared.
Results
TSR in PC or EUGS group was higher than that in the ETGS group for those with concomitant common bile duct stones (100% vs. 100% vs. 73.2%; p = 0.07) and for those without concomitant common bile duct stones (100% vs. 100% vs. 77.3%; p < 0.001). CSR in ETGS or EUGS group was higher than that in the PC group for those with concomitant common bile duct stones (96.2% vs. 100% vs. 87.5%; p = 0.41) and for those without concomitant common bile duct stones (94.1% vs. 100% vs. 63.0%; p = 0.006). Using Kaplan–Meier analysis, the overall recurrent risk was the highest in the PC group (p = 0.004).
Conclusions
In moderate and high-surgical risk patients with acute cholecystitis, EUGS provides significantly higher CSR with comparable TSR to PC. Thus, ETGS should be the first choice in those with concomitant common bile duct stones. Among the three patient groups, those who received PC had the highest rate of recurrence.

Keyword

Acute cholecystitis; Cholecystostomy; Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound

Figure

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  Fig. 1 Decision tree to have patients undergo ETGS, EUGS, or PC during the study period. CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; ETGS, endoscopic transpapillary gallbladder stenting; EUGS, endoscopic ultrasound-guided transmural gallbladder stenting; PC, percutaneous cholecystostomy. a)Patients were admitted for acute cholecystitis with sepsis during weekend when emergency ETGS or EUGS was not available.

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  Fig. 2 Endoscopic transpapillary gallbladder stenting technique. (A) Cystic duct cannulation; (B) gallbladder guidewire placement; (C) gallbladder stent placement.

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  Fig. 3 Endoscopic ultrasound-guided transmural gallbladder stenting technique. (A) Contrast injection into gallbladder; (B) guidewire looping in the gallbladder; (C) creating the fistula tract using a cystotome; (D) successful lumen-apposing metal stent (LAMS) deployment; (E) pus drainage with small gallstones through LAMS; (F) gallbladder wall inflammation seen via LAMS.

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  Fig. 4 Patient cohort between January 2016 and May 2019. CBD, common bile duct; ETGS, endoscopic transpapillary gallbladder stenting; EUGS, endoscopic ultrasound-guided transmural gallbladder stenting; PC, percutaneous cholecystostomy. a)Three and four patients who had unsuccessful ETGS crossed over to successful EUGS in those with and without concomitant CBD stones, respectively. b)Of 12 patients who received medical treatment only, all patients had clinical success. Two patients developed recurrence at one month and received cholecystectomy in the same admission whereas 4 patients had elective cholecystectomy without any recurrence. The remaining patients (n = 6) did not receive cholecystectomy due to their severe comorbidities with Charlson’s comorbidity index ≥ 6 (severe cardiac diseases, n = 2; advanced malignancy, n = 4). They had no recurrence during a median follow-up of 102 days (range, 84–1,448 days).

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  Fig. 5 Kaplan–Meier analysis demonstrating overall recurrent risk in ETGS vs. EUGS vs. PC groups after non-surgical gallbladder drainage in acute cholecystitis patients with or without concomitant common bile duct stones. PC, percutaneous cholecystostomy; ETGS, endoscopic transpapillary gallbladder stenting; EUGS, endoscopic ultrasound-guided transmural gallbladder stenting.

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