Endoscopic gallbladder drainage is typically reserved for patients with symptomatic gallbladder disease who are poor surgical candidates because of malignancy, underlying cirrhosis, severe cardiac disease, or other high-risk comorbid conditions. Endoscopic gallbladder drainage is usually performed in 2 clinical settings: acute cholecystitis and recurrent biliary colic. Although gallbladder disease in nonsurgical candidates is usually treated via a percutaneous cholecystostomy tube, this approach is associated with a significant rate of adverse events and high levels of patient dissatisfaction, and the long-term management of cholecystostomy tubes is often problematic (1–3). Percutaneous cholecystostomy tubes are often left in place on a long-term or permanent basis, known as “destination therapy.”
Endoscopic gallbladder drainage is particularly appealing because it provides internal gallbladder drainage without the need for a percutaneous catheter. Endoscopic gallbladder drainage can be performed via 2 approaches: transampullary or transmural. In my experience, both are highly effective but come with their own set of risks and benefits.
TRANSAMPULLARY GALLBLADDER DRAINAGE
Transampullary gallbladder drainage is accomplished via endoscopic retrograde (ERCP). In this approach, the bile duct is cannulated in the standard manner with standard ERCP accessories. A guidewire is used to selectively access the cystic duct and the gallbladder (Figure 1). Once the guidewire has passed into the gallbladder, a double pigtail 7Fr stent can be placed to allow gallbladder decompression and drainage with 1 pigtail coiled in the gallbladder itself and the other coiled in the second portion of the duodenum. Most double pigtail stents have side holes, further promoting drainage and lessening the chances of the stent itself becoming occluded.
Transampullary gallbladder drainage has been shown to be technically and clinically successful in approximately 80%–90% of patients (4,5). Although simple in concept, transampullary gallbladder drainage may be technically challenging to perform. Difficulties mostly center around obtaining guidewire access to the gallbladder via the cystic duct. Although obtaining guidewire access to the bile duct is usually relatively straightforward, in some patients, it can be quite challenging. In my experience, it is very difficult to predict whether guidewire access to the gallbladder will be achieved rapidly or with tremendous effort. The origin of the cystic duct may be at an unfavorable angle or location (or both), making passage of the wire into the duct itself difficult. In some cases, a cholangioscope may be needed to directly visualize the opening of the cystic duct to allow guidewire passage (Figure 2a,b). Furthermore, the cystic duct may be tortuous, and cystic duct anatomy and the spiral valves of Heister may further complicate transcystic wire advancement. Rarely, the cystic duct will be completely obstructed, rendering transampullary gallbladder drainage approaches useless.
In most cases, once guidewire access to the gallbladder has been obtained, stent placement is a simple matter unless the cystic duct is too narrow or angulated to accommodate the stent itself. I prefer to give intra-procedure and a short course of post-procedure antibiotics to these patients to reduce the risk of infection. Depending on the patient's overall health, transampullary stents that drain the gallbladder can be left in place indefinitely or changed periodically as needed. Risks of this approach include those of ERCP, stent obstruction, and cystic duct injury.
TRANSMURAL GALLBLADDER DRAINAGE
Transmural gallbladder drainage is an endoscopic ultrasound procedure, whereby the gallbladder itself is identified and accessed through either the gastric or duodenal wall. One or more stents can be placed across the cholecystoenterostomy to provide a route for gallbladder decompression. The stents used can be double-pigtail plastic stents, fully covered metal biliary stents, or lumen-apposing metal stents (LAMS). Data to date are highly encouraging (4,6,7).
The procedure is very similar to that used to endoscopically access and drain pancreatic pseudocysts and walled-off pancreatic necrosis. Using a linear echoendoscope, an area where the gallbladder closely abuts the stomach or duodenum is identified (if the gallbladder is not in close proximity to the bowel, transmural approaches may be impossible) (Figure 3a). The endoscopist can access the gallbladder via transmural puncture using a 19-gauge needle. The needle can be used to inject contrast to confirm access to the gallbladder and/or pass a wire into the gallbladder. The transmural tract can be dilated, if needed, using a biliary passage or balloon dilator. A stent can then be deployed across the tract with one end of the stent in the gallbladder and one end in the stomach or duodenum. Alternatively, if an electrocautery-enhanced LAMS is used (as I usually do), needle and wire-based approaches may be obviated, and the gallbladder can be accessed directly with LAMS deployment following in short order.
After deployment, the transmural stent can be left in place, dilated via a balloon catheter, or re-accessed for additional maneuvers including direct endoscopic removal of gallbladder stones or placement of one or more double pigtail drains into the gallbladder through the initial stent if a metal stent or LAMS was selected for the transmural conduit (Figure 3b,c). No firm guidelines exist regarding these maneuvers, and decisions in these realms are typically individualized (8). As with transampullary gallbladder drainage, I give patients both intra- and post-procedure antibiotics while performing transmural drainage. In practice, most transmural stents are placed indefinitely, but some data exist showing that they can be removed and that some patients can proceed to cholecystectomy in the future (9). Risks of transmural drainage include bleeding, bile leak, perforation, peritonitis, and stent dislodgement or obstruction.
Overall, endoscopic approaches to gallbladder drainage have a high success rate and an acceptable rate of adverse events. These techniques should be considered in nonsurgical candidates to potentially avoid long-term percutaneous catheter drainage.
CONFLICTS OF INTEREST
Guarantor of the article: Douglas G. Adler, MD, FACG, AGAF, FASGE.
Specific author contributions: D.G.A.: wrote the article.
Financial support: None.
Potential competing interests: D.G.A. is a consultant to Boston Scientific.
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