Endoscopic ultrasound-guided gallbladder drainage: a backdoor for biliary decompression?

We read with interest the retrospective study by Issa et al. [1] reporting the performance of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) as a rescue procedure to achieve biliary drainage in 28 patients with unresectable malignant distal biliary obstruction after failure of both endoscopic retrograde cholangiopancreatography (ERCP) and EUS-guided biliary drainage (EUS-BD). EUS-GBD was achieved using lumen-apposing metal stents (LAMSs) or self-expandable metal stents (SEMSs) in 26 patients (93 %) and two patients (7 %), respectively, with anchoring double-pigtail plastic stents used in 68 % of cases. The technical and clinical success rates were 100 % and 92.6 %, with delayed adverse events and stent patency > 30 days seen in 18 % and 82 % of cases, respectively.

Although these results are very encouraging, some issues need consideration. (i) The type of EUS-BD approach attempted before performing EUS-GBD, which has important implications on the decision to undergo gallbladder versus percutaneous transhepatic drainage, was not reported. (ii) Cholecystogastrostomy and cholecystojejunostomy were frequently performed in this setting more than 25 years ago [2]. In a comparative study, however, patients with gallbladder drainage in situ were 4.4 and 2.9 times more likely to have additional biliary surgery and interventions compared with those who underwent direct bile duct bypass [3]. (iii) The effectiveness of EUS-GBD completely depends on a patent cystic duct, which occurs in only 50 % of patients when evaluated at ERCP, with two-thirds of the remaining patients having tumors within 1 cm of the hepatocystic junction [4], which raises questions about the long-term patency of EUS-GBD.

We believe that EUS-GBD should be seen as the backdoor entry to the biliary system when both ERCP and EUS-BD have failed, and only when cystic duct patency is a priori confirmed and there is a distance of at least 1 cm between the tumor and the point of cystic duct implantation. Studies exploring the actual prevalence of the two aforementioned factors will be necessary to assess the real impact of EUS-GBD in this clinical setting.

Publication History

Article published online:
27 July 2021

• References

• 1 Issa D, Irani S, Law R. et al. Endoscopic ultrasound-guided gallbladder drainage as a rescue therapy for unresectable malignant biliary obstruction: a multicenter experience. Endoscopy 2021; 53 DOI: 10.1055/a-1259-0349.
• 2 Watanapa P, Williamson RC. Surgical palliation for pancreatic cancer: developments during the past two decades. Br J Surg 1992; 79: 8-20
• 3 Urbach DR, Bell CM, Swanstrom LL. et al. Cohort study of surgical bypass to the gallbladder or bile duct for the palliation of jaundice due to pancreatic cancer. Ann Surg 2003; 237: 86-93
• 4 Tarnasky PR, England RE, Lail LM. et al. Cystic duct patency in malignant obstructive jaundice. An ERCP-based study relevant to the role of laparoscopic cholecystojejunostomy. . Ann Surg 1995; 221: 265-271