EUS-guided gallbladder drainage: a learning curve modified by technical progress

Abstract

Introduction Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an efficacious and safe option for patients who cannot undergo cholecystectomy. It is a technically challenging procedure, requiring skills in EUS, and ERCP. The aim of this study was to define the learning curve for EUS-GBD.

Patients and methods Consecutive patients undergoing EUS-GBD by a single operator were included from a prospective registry over 5 years. Demographics, procedure information, post-procedure follow-up data, and information on adverse events were collected. Non-linear regression and CUSUM analyses were conducted for the learning curve. Clinical success was defined as resolution of cholecystitis post-procedure.

Results Forty-eight patients were included (58 % male, mean age 76 years). Twenty patients (42 %) had malignant cholecystitis. Most patients had lumen-apposing metal stents (LAMS) (15 mm, n = 29, 60 %; 10 mm, n = 8, 7 %). The remaining patients had FCSEMS (n = 9, 19 %) or plastic stents alone (n = 2, 4 %). Clinical success was achieved in 36 (86 %) of patients. Of the remaining 12, 7 were lost to follow-up and 5 had persistent cholecystitis. 9 patients (19 %) had adverse events including bleeding (n = 4), liver abscesses (n = 2), and hypotension. Two patients passed away post-procedure.

Median procedure time was 41 minutes (range 16 – 121 min), with the 41-minute time occurring during the 19th procedure. Procedure durations further reduced, with the last 10 procedures being 20 minutes or under (nonlinear regression p value P < 0.0001).

Conclusion Endoscopists experienced in EUS-GBD are expected to achieve a reduction in procedure time over successive cases, with efficiency reached at 41 minutes and a learning rate of 19 cases. Continued improvement is demonstrated with additional experience

• References

• 1 Akhan O, Akinci D, Ozmen MN. Percutaneous cholecystostomy. Eur J Radiol 2002; 43: 229-236
• 2 Súbtil JC. Gallbladder drainage guided by endoscopic ultrasound. World J Gastrointest Endosc 2010; 2: 203-209
• 3 Morse BC, Smith JB, Lawdahl RB. et al. Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy. Am Surg 2010; 76: 708-712
• 4 Hatzidakis AA, Prassopoulos P, Petinarakis I. et al. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Europ Radiol 2002; 12: 1778-1784
• 5 Adler DG. Avoiding the tube: ERCP and EUS approaches to gallbladder drainage as alternatives to percutaneous cholecystostomy in patients with cholecystitis. Gastrointest Endosc 2019; 89: 299-300
• 6 Minaga K, Yamashita Y, Ogura T. et al. Clinical efficacy and safety of endoscopic ultrasound-guided gallbladder drainage replacement of percutaneous drainage: A multicenter retrospective study. Digest Endosc 2019; 31: 180-187
• 7 Saumoy M, Tyberg A, Brown E. et al. Successful cholecystectomy after endoscopic ultrasound gallbladder drainage compared with percutaneous cholecystostomy, can it be done?. J Clin Gastroenterol 2019; 53: 231-235
• 8 Irani S, Ngamruengphong S, Teoh A. et al. Similar efficacies of endoscopic ultrasound gallbladder drainage with a lumen-apposing metal stent versus percutaneous transhepatic gallbladder drainage for acute cholecystitis. Clin Gastroenterol Hepatol 2017; 15: 738-745
• 9 Teoh A, Serna C, Penas I. et al. Endoscopic ultrasound-guided gallbladder drainage reduces adverse events compared with percutaneous cholecystostomy in patients who are unfit for cholecystectomy. Endoscopy 2016; 49: 130-138
• 10 Tyberg A, Saumoy M, Sequeiros EV. et al. EUS-guided Versus percutaneous gallbladder drainage: isn’t it time to convert?. J Clin Gastroenterol 2016; 52: 79-84
• 11 Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg 2012; 16: 2011-2025
• 12 Anderloni A, Buda A, Vieceli F. et al. Endoscopic ultrasound-guided transmural stenting for gallbladder drainage in high-risk patients with acute cholecystitis: a systematic review and pooled analysis. Surg Endosc 2016; 30: 5200-5208
• 13 Irani S, Baron TH, Grimm IS. et al. EUS-guided gallbladder drainage with a lumen-apposing metal stent (with video). Gastrointest Endosc 2015; 82: 1110-1115
• 14 Song TJ, Park DH, Eum JB. et al. EUS-guided cholecystoenterostomy with single-step placement of a 7F double-pigtail plastic stent in patients who are unsuitable for cholecystectomy: a pilot study (with video). Gastrointest Endosc 2010; 71: 634-640
• 15 Widmer J, Alvarez P, Gaidhane M. et al. Endoscopic ultrasonography-guided cholecystogastrostomy in patients with unresectable pancreatic cancer using anti-migratory metal stents: A new approach: EUS-guided cholecystogastrostomy. Digest Endosc 2014; 26: 599-602
• 16 de la Serna-Higuera C, Pérez-Miranda M, Gil-Simón P. et al. EUS-guided transenteric gallbladder drainage with a new fistula-forming, lumen-apposing metal stent. Gastrointest Endosc 2013; 77: 303-308
• 17 Jang JW, Lee SS, Park DH. et al. Feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients unsuitable for cholecystectomy. Gastrointest Endosc 2011; 74: 176-181
• 18 Itoi T, Binmoeller KF, Shah J. et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012; 75: 870-876
• 19 Moon JH, Choi HJ, Kim DC. et al. A newly designed fully covered metal stent for lumen apposition in EUS-guided drainage and access: a feasibility study (with videos). Gastrointest Endosc 2014; 79: 990-995
• 20 Teoh AYB, Binmoeller KF, Lau JYW. Single-step EUS-guided puncture and delivery of a lumen-apposing stent for gallbladder drainage using a novel cautery-tipped stent delivery system. Gastrointest Endosc 2014; 80: 1171
• 21 Tyberg A, Saumoy M, Kahaleh M. Using NOTES to salvage a misdeployed lumen-apposing metal stent during an endoscopic ultrasound-guided gastroenterostomy. Endoscopy 2017; 49: 1007-1008
• 22 Tyberg A, Zerbo S, Barthet M. et al. A novel technique for salvaging a dislodged lumen-apposing metal stent during creation of an endoscopic gastrojejunostomy. Gastrointest Endosc 2016; 83: 254
• 23 Yamashita Y, Takada T, Kawarada Y. et al. Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepato-Biliary-Pancr Surg 2007; 14: 91-97
• 24 Poincloux L, Rouquette O, Buc E. et al. Endoscopic ultrasound-guided biliary drainage after failed ERCP: cumulative experience of 101 procedures at a single center. Endoscopy 2015; 47: 794-801
• 25 Oh D, Park DH, Song TJ. et al. Optimal biliary access point and learning curve for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting. Therap Adv Gastroenterol 2017; 10: 42-53