Endoscopic Management of Acute Cholecystitis

Acute cholecystitis is a commonly encountered medical emergency that is managed surgically with excellent results. Recent experiences with endoscopic cystic duct stent placement and cholecystectomy using the NOTES (Natural Orifice Transluminal Endoscopic Surgery) approach have inspired endoscopists to identify other less invasive means for treating cholecystitis. The ability to access and drain obstructive bile ducts in real time using endoscopic ultrasound guidance has led to recent reports of successful gallbladder drainage using similar techniques. This article discusses the current state of the endoscopic management of acute and acalculous cholecystitis, and outlines a consensus approach to the management of these patients.

Key points

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In high-risk surgical patients with acute cholecystitis, alternative treatment modalities are required for gallbladder decompression.
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For patients in whom temporary decompression is preferred, nasocystic drainage guided by endoscopic retrograde cholangiopancreatography is an effective treatment option.
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For patients who require permanent decompression, transluminal drainage guided by endoscopic ultrasonography is an alternative treatment option.

Cholecystectomy, performed either laparoscopically or through open surgery, is the mainstay of the treatment of acute cholecystitis, which affects nearly 20 million Americans annually. Although the laparoscopic approach is less invasive and is the treatment of choice for a majority of patients, some critically or terminally ill patients may not be able to withstand the morbidity of surgery. Therefore a less invasive procedure, such as percutaneous gallbladder drainage, could be a life-saving treatment option or serve as bridge to elective surgery. Percutaneous drainage is technically easy to perform; however, the physical discomfort from the catheter renders this a less desirable option for patients with limited life expectancy from terminal cancer or those patients with contraindications to the procedure.

This article reviews the 2 endoscopic treatment approaches that are feasible for patients with acute cholecystitis, particularly for high-risk surgical candidates who require gallbladder decompression: (1) transpapillary drainage of the gallbladder at endoscopic retrograde cholangiopancreatography (ERCP) by nasocystic catheter or stent placement; and (2) endoscopic ultrasonography (EUS)-guided gallbladder drainage via the transluminal route.

Procedural indications and choice of technique

Endoscopic decompression of the gallbladder is usually attempted only when standard treatment options fail or are contraindicated. Specifically, endoscopic decompression is considered in patients with acute or acalculous cholecystitis who (1) are critically ill or have severe comorbidity that precludes a surgical cholecystectomy and/or (2) have contraindications for placement of a percutaneous cholecystostomy tube, such as the presence of large amounts of ascites, hypercoagulopathy, or an intervening loop of bowel between the diaphragm and the liver that precludes percutaneous access. Endoscopic management is contraindicated, however, in patients (1) with perforated gallbladder, (2) who are too unstable to undergo endoscopy or sedation, or (3) who are pregnant, because of the risks of radiation exposure from a prolonged procedure.

For patients who require only temporary gallbladder decompression as a bridge to elective surgery, transpapillary drainage by means of stenting or nasocystic catheter placement are effective options. The advantage of nasocystic catheters over stents is that they can be flushed periodically, whereas stents tend to clog easily. On the other hand, nasocystic catheters, unlike stents, are prone to dislodgment and can be a source of physical discomfort to patients. Some experts advocate the deployment of nasocystic catheters as a temporizing measure followed by placement of transpapillary internal stents as a bridge to elective surgery. For patients who require a more definitive treatment, such as high-risk surgical candidates, EUS-guided transluminal drainage of the gallbladder by means of internal stenting could offer permanent palliation.

Transpapillary Gallbladder Drainage

ERCP can aid in gallbladder decompression by facilitating access to the cystic duct. After successful cannulation of the common bile duct using an ERCP catheter, a 0.035-inch (0.889 mm) guide wire (stiff or hydrophilic) is advanced into the cystic duct and then the gallbladder ( Fig. 1 ). In patients with a difficult cystic duct configuration, the choice of a biliary catheter may vary: for a left-side cystic duct takeoff, a flexible-tip catheter (Swing-tip; Olympus Medical Systems, Tokyo, Japan) or a rotatable sphincterotome may be used; for a right-sided takeoff, a standard sphincterotome may be used because it usually bows toward the cystic duct when it takes off on the right side. Alternatively, the sphincterotome may be advanced deep into the bile duct, bowed, and then withdrawn slowly, so that the tip may position itself into the cystic duct opening on pull-down. When the gallbladder or the cystic duct cannot be opacified because of cholecystitis, a balloon is inflated below the expected takeoff of the cystic duct, and an occlusion cholangiogram obtained to allow cystic duct visualization. Alternatively, the cystic duct can be identified by mere manipulation of the guide wire. In some patients, SpyGlass-assisted cystic duct cannulation has been performed successfully, with good technical outcomes. Once the guide wire is advanced and coiled within the gallbladder lumen, the catheter is exchanged for a 5F to 7F pigtail nasocystic drainage tube or a 7F to 10F double-pigtail transpapillary stent. The length of the stent depends on lengths of the cystic duct and gallbladder lumen from the major duodenal papilla. When large-caliber (10F) stents are placed, a biliary sphincterotomy should be performed to minimize the chances of post-ERCP pancreatitis caused by the fulcrum effect.

EUS-Guided Transluminal Gallbladder Drainage

The therapeutic linear-array echoendoscope is used for EUS-guided transgastric/transduodenal gallbladder drainage. The drainage access point chosen is based on the smallest distance between the gallbladder and the enteral lumen (gastric antrum or the duodenal bulb). Theoretically, the risk of leakage into the peritoneum can be minimized if inflammatory adhesion exists between the gallbladder and enteral lumen. A 19-gauge needle punctures the gastric or the duodenal wall to access the gallbladder ( Fig. 2 ). A 0.035-inch guide wire is then passed through the needle and coiled within the gallbladder lumen. The fine-needle aspiration needle is then exchanged for a needle knife or stiff catheter, which is then advanced over the guide wire into the gallbladder lumen to create a fistula. The transmural tract is then sequentially dilated using a graded dilation catheter or a dilating balloon. To minimize the chances of bile leak, the balloon should not be inflated more than 6 mm. Following dilation, a nasocystic catheter, double-pigtail plastic stent, or self-expandable metal stent (SEMS) is deployed to facilitate biliary drainage within the enteral lumen.

A prototype novel lumen-apposing stent (AXIOS; Xlumena Inc, Mountain View, CA) that appears to minimize the risk of bile leakage and SEMS migration has been recently developed. The lumen-apposing stent is a fully covered, 10-mm diameter, nitinol, braided stent with bilateral anchor flanges. The diameter of the flanges, when fully expanded, is twice that of the “saddle” section and is designed to hold the tissue layers in apposition. The stent is delivered constrained through a 10.5F catheter and the delivery system is Luer locked to the proximal end of the biopsy port of the endoscope, which gives the endoscopist control of stent deployment. The handle enables a 2-step release of each flange. The distal flange is first deployed under EUS guidance, followed by proximal traction of the distal flange to place the target lumen in firm apposition to the duodenal or gastric walls. The proximal flange is then deployed under endoscopic guidance. The length of the stent (6 or 10 mm) is determined by the combined thickness of the interposed tissue.

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