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 Table of Contents  
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 76-78

Development of EUS-guided gallbladder drainage and current indications

1 Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
2 Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan

Date of Submission08-Dec-2017
Date of Acceptance04-Mar-2018
Date of Web Publication16-Apr-2018

Correspondence Address:
Dr. Takao Itoi
Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-Ku, Tokyo 160-0023
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_4_18

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How to cite this article:
Itoi T, Tsuchiya T, Sofuni A, Tanaka R, Tonozuka R, Honjo M, Mukai S, Fujita M, Yamamoto K, Asai Y, Kurosawa T, Tachibana S, Nagakawa Y. Development of EUS-guided gallbladder drainage and current indications. Endosc Ultrasound 2018;7:76-8

How to cite this URL:
Itoi T, Tsuchiya T, Sofuni A, Tanaka R, Tonozuka R, Honjo M, Mukai S, Fujita M, Yamamoto K, Asai Y, Kurosawa T, Tachibana S, Nagakawa Y. Development of EUS-guided gallbladder drainage and current indications. Endosc Ultrasound [serial online] 2018 [cited 2020 Jul 15];7:76-8. Available from: http://www.eusjournal.com/text.asp?2018/7/2/76/230237

Acute calculous and non-calculous cholecystitis is one of the most common intra-abdominal infections. Although the imaging diagnosis of acute cholecystitis (AC) is not complicated, the determination of AC severity leading to the selection of treatment, conservative therapy, gallbladder drainage, and surgical cholecystectomy is still controversial even with the latest data analyses based on the Tokyo Guidelines 2013.[1],[2] However, the mortality and morbidity rates from cholecystectomy in high-risk patients remain high. Moreover, surgical cholecystectomy cannot always be performed for several reasons (e.g., few surgery-related staff particularly at night). Thus, such patients have been treated using temporary therapy regimens such as percutaneous transhepatic interventions and endoscopic transpapillary interventions;[3],[4] although, no obvious discrepancy in the outcome has been found between the two interventions.[5] In 2007, Baron and Topazian introduced EUS-guided gallbladder drainage (EUS-GBD) using a double pigtail stent as a new technique.[6] Thereafter, studies on EUS-GBD using dedicated metal stents were published by Jang et al. in 2011[7] and Itoi et al. in 2012.[8] Since then, several studies and case series on EUS-GBD using metal stents have been published.[9],[10],[11]

Although EUS-GBD has become widely used among skilled endosonographers, endoscopic transpapillary gallbladder drainage (ETGBD) is commonly performed by skilled ERCP endoscopists. In their study involving a meta-analysis and systematic review, Khan et al. showed that the technical and clinical success rates of EUS-GBD were superior to those of ETGBD.[12] Theoretically, a large target and a short access route allow EUS-GBD to have a high success rate. However, it is interesting to note that EUS-GBD using a plastic stent or a naso-gallbladder drainage catheter more likely has adverse events than EUS-GBD using a metal stent.[12] In contrast, newly developed bi-flanged lumen-apposing metal stents with diameters ranging from 10 mm to 15 mm enable the effective drainage of gallbladder content and afford less stent migration. Thus, if the single-step stent delivery system could be used, EUS-GBD appears to be the most effective and safest procedure for treating AC. Based on the latest outcome, the Tokyo Guidelines 2018 indicate that EUS-GBD may be one of the viable options for AC treatment based on reports in the literature.[13]

The present indications of EUS-GBD are shown in [Table 1]. To date, patients who have undergone EUS-GBD have been described by most reports as noncandidates for surgery owing to their critical illness. What then is the possibility of conducting EUS-GBD in those who are candidates for surgery? EUS-GBD appears to be a potential alternative to surgical intervention because it allows not only gallbladder drainage but also stone removal from the gallbladder. However, the recurrence of stones and cholecystitis may be inevitable as long as the gallbladder is present. Once the gallbladder is completely removed surgically, there should be no recurrence of cholecystitis theoretically. Thus, surgical intervention should be the gold standard therapy in noncritically ill patients with AC being a safe and reliable procedure.
Table 1: Present indications of EUS-guided gallbladder drainage

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Recently, a bridge to surgery in the form of preoperative biliary drainage has attracted attention.[14] Surgical interventions are not always possible because of the unavailability of surgeons or the medical staff. In such a case, percutaneous transhepatic drainage or endoscopic transpapillary drainage has been preoperatively performed for AC treatment. Theoretically, transpapillary interventions by ERCP may have few obstacles during the operation because of the transluminal approach. For percutaneous interventions, some obstacles such as difficulty in removing the gallbladder wall attached to the liver side may be experienced during the operation. However, most surgeons do not object to performing cholecystectomy after percutaneous transhepatic interventions. They indicate that there is no discrepancy in the difficulty of removing the gallbladder wall from the liver between the anastomotic site and the liver (gallbladder) bed. In EUS-GBD, however, the anastomotic site is in the GI tract (duodenal or gastric wall), and this can be an obstacle to removing the gallbladder wall and closing the anastomotic site in the GI tract wall. The difficulty of the operation is still controversial. However, if the number of EUS-GBD cases continues to increase as one of the preoperative gallbladder drainage therapies, the intraoperative management of the anastomotic site should be established in the near future.

The conversion of percutaneous transhepatic gallbladder drainage (PTGBD) to EUS-GBD is preferable for patients because the PTGBD tube involves external drainage and is troublesome in daily life. In contrast, EUS-GBD involves internal drainage and is cosmetically and functionally better than PTGBD. Technically, although the gallbladder does not show distention except in the predrainage status, the PTGBD tube enables saline injection to distend the gallbladder. Furthermore, even if EUS-GBD fails, PTGBD works well as a safety route.

Although PTGBD and ETGBD have been used for the treatment of AC patients, they are not always successful because of anatomical and technical issues. EUS-GBD may be useful for such patients in hospitals with EUS expertise as salvage therapy.

For the last indication, EUS-GBD can be used as an alternative to failed EUS-guided biliary drainage (EUS-BD). At present, EUS-BD is performed worldwide in case of failed ERCP, and dedicated devices for EUS-BD have been developed.[15],[16] However, EUS-BD is not always successful because of anatomical and technical issues. If the gallbladder has a connection with the proximal bile duct via the cystic duct, the gallbladder may be able to contribute to the biliary decompression as a salvage drainage route. We first suggested that EUS-GBD is a possible alternative to failed EUS-BD.[17] Notably, the gallbladder stent showed no occlusion during 14 months until the patient's death caused by the primary pancreatic cancer. Imai et al. also reported the usefulness of EUS-GBD as an alternative to failed EUS-BD.[18]

In conclusion, EUS-GBD appears to be a promising drainage technique for the treatment of acute cholecystitis because of its effectiveness and safety. More high-quality studies are necessary for the future to emphasize the superiority of EUS-GBD over other gallbladder drainages.

  References Top

Yokoe M, Takada T, Hwang TL, et al. Validation of TG13 severity grading in acute cholecystitis: Japan-Taiwan collaborative study for acute cholecystitis. J Hepatobiliary Pancreat Sci 2017;24:338-45.  Back to cited text no. 1
Endo I, Takada T, Hwang TL, et al. Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study. J Hepatobiliary Pancreat Sci 2017;24:346-61.  Back to cited text no. 2
Itoi T, Coelho-Prabhu N, Baron TH. Endoscopic gallbladder drainage for management of acute cholecystitis. Gastrointest Endosc 2010;71:1038-45.  Back to cited text no. 3
Itoi T, Kawakami H, Katanuma A, et al. Endoscopic nasogallbladder tube or stent placement in acute cholecystitis: A preliminary prospective randomized trial in Japan (with videos). Gastrointest Endosc 2015;81:111-8.  Back to cited text no. 4
Itoi T, Takada T, Hwang TL, et al. Percutaneous and endoscopic gallbladder drainage for acute cholecystitis: International multicenter comparative study using propensity score-matched analysis. J Hepatobiliary Pancreat Sci 2017;24:362-8.  Back to cited text no. 5
Baron TH, Topazian MD. Endoscopic transduodenal drainage of the gallbladder: Implications for endoluminal treatment of gallbladder disease. Gastrointest Endosc 2007;65:735-7.  Back to cited text no. 6
Jang JW, Lee SS, Park DH, et al. Feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients unsuitable for cholecystectomy. Gastrointest Endosc 2011;74:176-81.  Back to cited text no. 7
Itoi T, Binmoeller KF, Shah J, et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012;75:870-6.  Back to cited text no. 8
Walter D, Teoh AY, Itoi T, et al. EUS-guided gall bladder drainage with a lumen-apposing metal stent: A prospective long-term evaluation. Gut 2016;65:6-8.  Back to cited text no. 9
Moon JH, Choi HJ, Kim DC, et al. Anewly designed fully covered metal stent for lumen apposition in EUS-guided drainage and access: A feasibility study (with videos). Gastrointest Endosc 2014;79:990-5.  Back to cited text no. 10
Teoh AY, Binmoeller KF, Lau JY. Single-step EUS-guided puncture and delivery of a lumen-apposing stent for gallbladder drainage using a novel cautery-tipped stent delivery system. Gastrointest Endosc 2014;80:1171.  Back to cited text no. 11
Khan MA, Atiq O, Kubiliun N, et al. Efficacy and safety of endoscopic gallbladder drainage in acute cholecystitis: Is it better than percutaneous gallbladder drainage? Gastrointest Endosc 2017;85:76-87.e3.  Back to cited text no. 12
Mori Y, Itoi T, Baron TH, et al. Tokyo guidelines 2018: Management strategies for gallbladder drainage in patients with acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018;25:87-95.  Back to cited text no. 13
Umeda J, Itoi T. Current status of preoperative biliary drainage. J Gastroenterol 2015;50:940-54.  Back to cited text no. 14
Umeda J, Itoi T, Tsuchiya T, et al. Anewly designed plastic stent for EUS-guided hepaticogastrostomy: A prospective preliminary feasibility study (with videos). Gastrointest Endosc 2015;82:390-6.e2.  Back to cited text no. 15
Song TJ, Lee SS, Park DH, et al. Preliminary report on a new hybrid metal stent for EUS-guided biliary drainage (with videos). Gastrointest Endosc 2014;80:707-11.  Back to cited text no. 16
Itoi T, Binmoeller K, Itokawa F, et al. Endoscopic ultrasonography-guided cholecystogastrostomy using a lumen-apposing metal stent as an alternative to extrahepatic bile duct drainage in pancreatic cancer with duodenal invasion. Dig Endosc 2013;25 Suppl 2:137-41.  Back to cited text no. 17
Imai H, Kitano M, Omoto S, et al. EUS-guided gallbladder drainage for rescue treatment of malignant distal biliary obstruction after unsuccessful ERCP. Gastrointest Endosc 2016;84:147-51.  Back to cited text no. 18


  [Table 1]


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