ENDOSCOPIC TRANSPAPILLARY GALLBLADDER DRAINAGE FOR MANAGEMENT OF THE PATIENT WITH ACUTE CALCULUS CHOLECYSTITIS WHO WAS UNSUITABLE FOR URGENT CHOLECYSTECTOMY

Aims:

Endoscopic transpapillary gallbladder drainage (ETGBD) is useful modality for patients who are no candidate for urgent cholecystectomy. We aim to evaluate the safety and efficacy of ETGBD by using either endoscopic traspapillary gallbladder stenting (ETGBS) or endoscopic nasogallbladder drainage (ENGBD) for managing acute cholecystitis (AC).

Methods:

From July 2014 to November 2018, 171 patients (77 females; mean age 72.8 ± 14.1 years) with AC who tried to perform ETGBD were retrospectively reviewed. Their technical success rate, clinical success rate, adverse event, clinical progress was evaluated. In ETGBS group, long term stent patency, recurrence of AC or occurrence of cholelithiasis were also analyzed.

Results:

The technical success rates and clinical success rate for ETGBD was 94.2% (161/171), and 99.3% (160/161), respectively. The adverse event rates occurred 6.4% (mild pancreatitis:7, post EST bleeding:3, bile duct hemorrhage:1), but all were treated by conservative management and endoscopic hemostasis. The clinical courses of all patients were as follows: two (1.1%) died of pneumonia aggravation, fifty-nine (34.5%) of interval cholecystectomy, the remaining of 110 (64.4%) were subsequently treated conservatively. ETGBS group (n = 89, mean age 78.4 ± 11.6) had more severe comorbidities with dementia, less performing cholecystectomy, and older than ENGBD (n = 72, mean age 65.9 ± 14.2) group. In ENGBD group, 4 patients successfully received ETGBS conversion and 45 patients underwent cholecystectomy. Thirty-one patients with prior percutaneous transhepatic gallbladder drainage (PTGBD) was subsequently performed ETGBS due to their surgical high risk. There was no stent dislodgement in ETGBS group, but one patient recurred AC immediately after PTGBD removal and six patient occurred acute cholangitis with cholelithiasis. Twenty-four patients were followed up without ETGBS removal for more than 6 months and their median complication-free interval was 303 days [IQR 267 – 413] by the Kaplan Meier method.

Conclusions:

ETGBD is technically feasible and effective therapy for patients who are not candidate for urgent cholecystectomy. Successful ETGBS patients had rarely developing cholelithiasis but fewer recurrences of AC. And also, ETGBS may be useful alternative treatment option for high-risk patients with severe comorbidities after PTGBD.