Introduction

Acute cholecystitis has been managed with laparoscopic cholecystectomy in surgically fit patients. In patients who are high‐risk surgical candidates, percutaneous transhepatic gallbladder drainage (PT‐GBD) has traditionally been the treatment of choice [1,2]. In recent years, internal drainage of the gallbladder using an endoscopic ultrasound‐guided transmural approach has emerged as a feasible and safe alternative [3–5]. Technical and clinical success were achieved in 95.3% and 90.8% of patients, respectively [6]. The technique was first described in 2007 [7]. In initial studies, the gallbladder was drained with transmural nasobiliary drainage tubes or plastic stents [8,9]. In recent years, the development of lumen‐apposing metal stents (LAMS) has gained widespread popularity due to the ease of deployment and lower concern for bile leakage [3,5,10]. LAMS also allows for subsequent advanced procedures such as stone removal [11]. According to the latest Tokyo Guidelines 2018, endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) could be considered an alternative in high‐volume centers when performed by skilled endoscopists [12]. Certain technical aspects and controversies with EUS‐GBD are discussed in this chapter.

Background concept

The gallbladder can be drained with the EUS transmural approach via the antrum or duodenum. In other words, a cholecystogastric or cholecystoduodenal anastomosis is being created endoscopically. However, the gallbladder and the antrum or duodenum are inherently separate organs that are not adhered to each other. Therefore, there is a risk of stent migration, bile leakage, and pneumoperitoneum. Therefore, the puncture site and choice of stent determine the integrity of the anastomosis, and thus the success of the procedure.

Choice of stents: metal stents versus plastic stents

Initial studies reported the use of EUS‐guided insertion of nasocholecystic drains [8,9]. A cholecystogram was performed 48–72 hours later after sepsis subsided, and the nasocholecystic drain was exchanged for a double pigtail or was removed. When compared to PT‐GBD, EUS‐GBD with nasocholecystic drain showed similar rates of technical (97% vs. 97%) and clinical (100% vs. 96%) success [13]. The median postprocedure pain score was significantly lower after EUS‐GBD than after PT‐GBD [13]. This may be preferable in patients in whom cholecystectomy is contemplated in the future. However, plastic stents are easily occluded due to the narrow lumen. Fully covered self‐expandable metal stents have a larger lumen than plastic double pigtail stents. However, they are not designed for transluminal drainage and do not have tissue apposition ability. Thus, they are prone to stent migration and may result in leakage and peritonitis.

LAMS were designed for transluminal drainage. All LAMS presently available on the market are initially intended for drainage of pancreatic fluid collections. They were designed with properties of tissue apposition and a large lumen to prevent stent occlusion. They are made of braided nitinol mesh with widely flared or dumbbell‐shaped flanges. All models are also covered with silicone membrane. Covered stents help to prevent leakage of air and bile. The silicone lining also impedes tissue ingrowth, making LAMS easily removable when needed [14]. LAMS that are currently available in the market are listed in Table 46.1. The larger lumens of LAMS allow for quick and effective drainage of infectious material and allows for further transluminal interventions via the stent in the gallbladder. A range of different diagnostic and interventional procedures through the stent, such as magnifying endoscopy, laser lithotripsy and basket mechanical lithotripsy for stone clearance, have also been reported in the gallbladder [11].

Several studies comparing EUS‐GBD and PT‐GBD have been published [15–18]. The two procedures have similar rates of technical (EUS‐GBD 85.7–96.6% vs. PT‐GBD 99–100%) and clinical success (EUS‐GBD 89.8–95% vs. PT‐GBD 86–94.9%) [15,16,18]. PT‐GBD has been shown to be associated with more adverse events and more unplanned admissions [16], and also to have a higher need for reintervention [15]. In addition, a meta‐analysis that included five comparative studies (206 patients in the EUS‐GBD group vs. 289 patients in the PT‐GBD group) concluded that EUS‐GBD had fewer adverse events than PT‐GBD (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.18–1.00; P = 0.05; I² = 66%), shorter hospital stays with pooled standard mean difference of –2.53 (95% CI –4.28 to –0.78; P = 0.005; I² = 98%), and required significantly fewer reinterventions (OR 0.16, 95% CI 0.04–0.042; P <0.001; I² = 32%) resulting in significantly fewer unplanned readmissions (OR 0.16, 95% CI 0.05–0.53; P = 0.003; I² = 79%) [19].

EUS‐GBD with LAMS

LAMS can be inserted by delivery systems that are with or without cautery enhanced tip. For LAMS without a cautery tip, the conventional method of EUS‐guided insertion is required. The procedure is as follows.

1. The gallbladder is identified using a linear echoendoscope. A suitable puncture site without intervening blood vessels is then located in the gastric antrum or the duodenum. According to published data, there is no difference between the efficacy and adverse events of the procedure when the puncture site is in the gastric antrum or duodenum [16,20]. However, there are several practical reasons to consider.
   
   
   
   1. By anatomy, the duodenal bulb is much closer to the gallbladder when compared with the antrum. This may potentially decrease the tension of the stent, thus causing less buried stent syndrome and stent migration.
      
   2. The risk of food reflux into the gallbladder, especially in large‐calibre metal stents, is lower with the transduodenal approach.
      
   3. There is some suggestion that cholecystectomy after EUS‐GBD may be less technically demanding via the trangastric approach, since repair of the gastric wall is safer and easier than repair of the duodenal wall. However, a comparative study did not show any significant difference [21].
   
   

   Thus, these points should be considered when deciding on the site for drainage of the gallbladder.

   
   
2. The gallbladder is punctured with a 19‐gauge needle, and the position is confirmed by the aspiration of bile or contrast injection and visualized using fluoroscopy (Figure 46.1). Most of the time, aspiration of bile is adequate to confirm the position. The injection of contrast will double confirm the position but may induce flare‐up of sepsis and should be minimized (Figure 46.2
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