Clin Endosc.  2020 Nov;53(6):678-685. 10.5946/ce.2019.186.

Practical Approaches for High-Risk Surgical Patients with Acute Cholecystitis: The Percutaneous Approach versus Endoscopic Alternatives

• Rerknimitr R
• Pham KC

• KMID: 2511227
• DOI: http://doi.org/10.5946/ce.2019.186

Abstract

In high-risk surgical patients with acute cholecystitis who are not candidates for early laparoscopic cholecystectomy, gallbladder (GB) drainage is an alternative treatment option. Percutaneous transhepatic gallbladder drainage (PTGBD) is a recommended first line intervention because of its high efficacy and feasibility in most centers. However, with the advent of endoscopic accessories and technology, endoscopic GB drainage has been chosen as a more favorable choice by endoscopists. Endoscopic transpapillary gallbladder drainage (ETGBD) can be performed under either fluoroscopic or peroral cholangioscopic guidance via endoscopic retrograde cholangiopancreatography by the transpapillary placement of a long double-pigtail stent. In a patient with common bile duct stones, this procedure is accompanied with stone removal. ETGBD is especially useful for acute cholecystitis patients who are contraindicated for PTGBD or those with severe coagulopathy, thrombocytopenia, and abnormal anatomy. Moreover, the advantage of ETGBD is its preservation of the external GB structure. Thereby it would not disturb the future cholecystectomy. Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic, fully covered metallic, or lumen-apposing metal stents transmurally has emerged as a modality for GB drainage with higher technical and clinical success rates. EUS-GBD can provide a more permanent GB drainage than PTGBD and ETGBD.

Keyword

Acute cholecystitis; Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound; Gallbladder drainage

Figure

• 

  Fig. 1. The algorithm for acute cholecystitis (AC) management is dependent on severity grading. ASA-PS, anesthesiologists physical status classification score; CCI, Charlson comorbidity index; ETGBD, endoscopic transpapillary gallbladder drainage; EUS-GBD, endoscopic ultrasound-guided gallbladder drainage; LC, laparoscopic cholecystectomy; PTGBD, percutaneous transhepatic gallbladder drainage.

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  Fig. 2. Endoscopic transpapillary gallbladder drainage (ETGBD) under fluoroscopic guidance. (A) ETGBD accesses the gallbladder lumen through the cystic duct via a selective guidewire. (B) ETGBD placement of a transpapillary, transcystic double-pigtail 7 F–15-cm stent in the duodenum.

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  Fig. 3. Endoscopic transpapillary gallbladder drainage with the SpyGlass cholangiopancreatoscopy system. (A) Identifying a slit-like opening (arrow) of the cystic duct using a cholangioscope. (B) Cannulation into the slit-like opening (arrow) by a 0.025 guidewire. (C) Insertion of a zigzag-shaped guidewire in the cystic duct. (D) Placement of a transpapillary, transcystic double-pigtail 7 F–15-cm stent into the gallbladder.

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  Fig. 4. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). (A) EUS-GBD with lumen-apposing metallic stent (LAMS). (B) Gallstones moved into the duodenum via LAMS. (C) LAMS fully expanded with the diameter allowing access to the gallbladder by a slim endoscope.

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