Feasibility of the conversion of percutaneous cholecystostomy to internal transmural endoscopic ultrasound-guided gallbladder drainage.

Percutaneous cholecystostomy, or percutaneous transhepatic gall bladder drainage (PTGBD) has traditionally been performed in patients suffering from acute cholecystitis and who are at a high risk for cholecystectomy. It can be a temporary measure to allow drainage of the gallbladder before the patient could be reassessed for surgery, or it could be a definite means of allowing long-term gallbladder drainage. Nevertheless, PTGBD is associated with a 0–25% risk of tube-related complications including dislodgement, leakage, and blockade.[1] Furthermore, the external catheter is associated with discomfort, pain, and cosmetic disfigurement, and continued care for the cholecystostomytube is required.

Therefore, endoscopic alternatives to gallbladder drainage have been developed.[2] These include endoscopic transpapillary gallbladder drainage and endoscopic ultrasound (EUS)-guided gallbladder drainage (EGBD).[34567] Recently, EGBD is gaining popularity as the procedure of choice because multiple retrospective studies have shown that the procedure is associated with reduced risk of adverse events, unplanned admissions, and re-interventions compared to PTGBD.[89101112] Furthermore, peroral cholecystostomy through the stent for gallstone removal is feasible and complete stone clearance could be achieved in 88% of the patients.[13]

EGBD could be performed by plastic stents, biliary covered metal stents, or lumen apposing metal stents (LAMS).[1415] There are no studies comparing the efficacy and outcomes of different types of stents for EGBD. However, when performing EGBD, the integrity of the anastomosis between the gallbladder and gastrointestinal tract depends on the properties of the stents. Hence, it is reasonable to recommend the use of biliary covered metal stents or LAMS over plastic stents for EGBD to prevent the chance of leak or migration. Furthermore, in a study comparing the lumen apposing force (LAF) of different types of LAMS, it was observed that, even with LAMS, different stent designs would affect the LAF.[15] Hence, LAMS with higher LAF should be recommended for performance of EGBD. The use of these stents may in turn avoid adverse events as reported in the current study by Chantarojarasiri et al. in this issue of the Journal.[16]

On the other hand, EGBD could be performed in patients suffering from acute cholecystitis or as a method to convert percutaneous cholecystostomy to internal drainage.[17] As illustrated in the current study,[16] the benefit of converting percutaneous cholecystostomy to internal drainage is avoidance of an external catheter and potential complications associated with the use of these catheters. However, it is also important is note that not all gallbladders are the same when performing EGBD. In patients with prior percutaneous drainage, the gallbladder is frequently fibrotic and contracted. Thus, it may be more difficult to perform EUS-guided drainage. One could use the percutaneous catheter to inject saline or contrast to distend the gallbladder. However, the presence of a patent cystic duct may limit the effectiveness of distending the gallbladder.

In conclusion, EGBD is gaining popularity worldwide for gallbladder drainage in patients who are not candidates for cholecystectomy. A randomized trial is currently underway to compare both techniques in high-risk patients. EGBD may replace percutaneous drainage as the procedure of choice in patients who are at high-risk for cholecystectomy.