Clin Endosc.  2020 Mar;53(2):221-229. 10.5946/ce.2019.099.

A New Technique of Endoscopic Transpapillary Gallbladder Drainage Combined with Intraductal Ultrasonography for the Treatment of Acute Cholecystitis

• Sagami R
• Hayasaka K
• Ujihara T
• Nakahara R
• Murakami D
• Iwaki T
• Suehiro S
• Katsuyama
• Harada H
• Amano Y

• KMID: 2500890
• DOI: http://doi.org/10.5946/ce.2019.099

Abstract

Background/Aims
Endoscopic transpapillary gallbladder drainage (ETGBD) is useful for the treatment of acute cholecystitis; however, the technique is difficult to perform. When intraductal ultrasonography (IDUS) is combined with ETGBD, the orifice of the cystic duct in the common bile duct may be more easily detected in the cannulation procedure. The aim of this study was to evaluate the efficacy of ETGBD with IDUS compared with that of ETGBD alone.
Methods
A total of 100 consecutive patients with acute cholecystitis requiring ETGBD were retrospectively recruited. The first 50 consecutive patients were treated using ETGBD without IDUS, and the next 50 patients were treated using ETGBD with IDUS. Through propensity score matching analysis, we compared the clinical outcomes between the groups. The primary outcome was the technical success rate.
Results
The technical success rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (92.0% vs. 76.0%, p=0.044). There was no significant difference in procedure length between the two groups (74.0 min vs. 66.7 min, p=0.310). The complication rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (6.0% vs. 0%, p<0.001); however, only one case showed an IDUS technique-related complication (pancreatitis).
Conclusions
The assistance of IDUS may be useful in ETGBD.

Keyword

Acute cholecystitis; Cystic duct; Endoscopic retrograde cholangiopancreatography; Endoscopic transpapillary gallbladder drainage; Intraductal ultrasonography

Figure

• 

  Fig. 1. Diagnostic procedure and classification criteria according to the severity grade of acute cholecystitis. Drainage is usually indicated for inoperable patients with grade III, grade II, or grade I (selected patients only) acute cholecystitis. CRP, C-reactive protein; CT, computed tomography; PT-INR, prothrombin time-international normalized ratio; WBC, white blood cell.

• 

  Fig. 2. Technique of endoscopic transpapillary gallbladder drainage with intraductal ultrasonography (IDUS). (A, B) The IDUS probe was slowly pulled out from the upper bile duct to the papilla. (C, D) The portal vein (PV) was adjusted to be at the 3 o’clock position. The left side of the patient was revealed as the 3 o’clock position and the dorsal side was the 12 o’clock position. The cystic duct (CD) was detected around the common bile duct (CBD). The orifice of the CD is shown by a white square. The lumen of the CBD is indicated by a white triangle. The partition wall between the orifice and the CBD is indicated by a black arrow, and the PV is shown by a white arrow. (E) The position in which the partition wall became invisible on the IDUS image was the location of the CD branching point (orifice) from the CBD. (F) CD cannulation was done with the guidewire.

• 

  Fig. 3. Clinical courses of 100 patients with acute cholecystitis treated using endoscopic transpapillary gallbladder drainage (ETGBD). EUS-GBD, endoscopic ultrasound-guided gallbladder drainage; IDUS, intraductal ultrasonography; PTGBA/D, percutaneous transhepatic gallbladder aspiration/drainage.

• 

  Fig. 4. Variations of the orifice of the cystic duct (CD) on intraductal ultrasonography (IDUS) examination. (A) The o’clock position of the direction of the CD orifice was determined using IDUS. The directions were described as in a clock face, with the common bile duct as the center, the dorsal side as the 12 o’clock direction, and the right side as the 9 o’clock direction. (B) The position of the bifurcation of the CD and extrahepatic bile duct was divided into the following 3 types: distal, middle, and proximal. (C) Three subgroups based on the angle of the orifice of the CD: a) right upper branch; b) right downward branch; and c) left upper branch.

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