EUS-guided gallbladder drainage in patients with cirrhosis: results of a multicenter retrospective study

Abstract

Background and study aims Cirrhosis has historically been considered a relative, if not absolute, contraindication to cholecystectomy. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been developed for use in non-operative candidates with cholecystitis; however, little data exist for use of the procedure in patients with cirrhosis.

Patients and methods This was a retrospective series involving two large tertiary referral centers performing EUS-GBD. Patients with cirrhosis who underwent EUS-GBD for cholecystitis between August 2014 and December 2018 were identified. The primary endpoint was the rate of technical success, defined as EUS-guided placement of a lumen-apposing metal stent (LAMS) from duodenum to gallbladder. Patient demographics, procedural details, adverse events (AEs), post-procedural symptoms, and clinical success were recorded.

Results Fifteen patients (9 females, 6 males) with cirrhosis underwent EUS-GBD during the study period. Mean patient age was 61 ± 17.1yrs, mean MELD-Na 15 ± 7. Etiology of cirrhosis was HCV (n = 2), alcohol (n = 4), non-alcoholic fatty liver disease (n = 8), and autoimmune hepatitis (n = 1).

The technical success rate was 93.3 % and mean procedure time was 64 ± 59 minutes. Initial puncture site was duodenum (n = 11), stomach (n = 3) and jejunum (n = 1) and portion of gallbladder used for drainage was neck (n = 4) and body (n = 11). Fourteen patients went on to clinical success and two AEs occurred in this cohort. One decompensation event occurred in a patient with Child-Pugh class C disease 3 weeks post-procedure. Mean length of follow-up was 373 ± 367.3 days; one death occurred due to underlying malignancy.

Conclusion EUS-GBD is safe and efficacious in managing cholecystitis in patients with Child-Pugh A and B cirrhosis who are non-operative candidates. Further studies are needed to determine optimal patient selection and procedural technique.

• References

• 1 Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg 2012; 16: 2011-2025
• 2 Csikesz NG, Tseng JF, Shah SA. Trends in surgical management for acute cholecystitis. Surgery 2008; 144: 283-289
• 3 Agresta F, Campanile FC, Vettoretto N. et al. Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbeckʼs Arch Surgery 2015; 400: 429-453
• 4 Chopra S, Dodd III GD, Mumbower AL. et al. Treatment of acute cholecystitis in non-critically ill patients at high surgical risk: comparison of clinical outcomes after gallbladder aspiration and after percutaneous cholecystostomy. Am J Roentgenol 2001; 176: 1025-1031
• 5 Ito K, Fujita N, Noda Y. et al. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial. Am J Roentgenol 2004; 183: 193-196
• 6 Patel M, Miedema BW, James MA. et al. Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis. Am Surgeon 2000; 66: 33
• 7 Itoi T, Sofuni A, Itokawa F. et al. Endoscopic transpapillary gallbladder drainage in patients with acute cholecystitis in whom percutaneous transhepatic approach is contraindicated or anatomically impossible (with video). Gastrointest Endosc 2008; 68: 455-460
• 8 Oku T, Horii T, Masaka T. et al. Clinical comparison of endoscopic naso-gallbladder drainage versus percutaneous transhepatic gallbladder drainage for acute cholecystitis. Nihon Shokakibyo Gakkai Zasshi 2013; 110: 989-997
• 9 Granlund A, Karlson BM, Elvin A. et al. Ultrasound-guided percutaneous cholecystostomy in high-risk surgical patients. Langenbeckʼs Arch Surg 2001; 386: 212-217
• 10 Baron TH, Topazian MD. Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease. Gastrointest Endosc 2007; 65: 735-737
• 11 Itoi T, Coelho-Prabhu N, Baron TH. Endoscopic gallbladder drainage for management of acute cholecystitis. Gastrointest Endosc 2010; 71: 1038-1045
• 12 Park JK, Woo YS, Noh DH. et al. Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study. Gastrointest Endosc 2018; DOI: 10.1016/j.gie.2018.03.015.
• 13 Harvey VS. Incidence of cholelithiasis among patients with cirrhosis and portal hypertension. Gastrointest Radiol 1988; 13: 347-350
• 14 Shi X, Jin S, Wang S. et al. Gallbladder perforation in a patient with alcoholic liver cirrhosis and asymptomatic gallstones: A case report. Medicine 2018; 97: e0414
• 15 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 3: 446-454
• 16 Angeli P, Bernardi M, Villanueva C. et al. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69: 406-460
• 17 Singer M, Deutschman CS, Seymour CW. et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). Jama 2016; 315: 801-10
• 18 Baron TH, Grimm IS, Gerber DA. Liver transplantation after endoscopic ultrasound–guided cholecystoduodenostomy for acute cholecystitis: a note of caution. Liver Transplant 2015; 21: 1322-1323
• 19 Baron TH, Zacks S, Grimm IS. Endoscopic ultrasound–guided cholecystoduodenostomy for acute cholecystitis in a patient with thrombocytopenia and end-stage liver disease awaiting transplantation. Clin Gastroenterol Hepatol 2015; 13: e13-14
• 20 Friedman LS. The risk of surgery in patients with liver disease. Hepatology 1999; 29: 1617-1623
• 21 Curro G, Iapichino G, Melita G. et al. Laparoscopic cholecystectomy in Child-Pugh class C cirrhotic patients. J Soc Laparoendosc Surgeons 2005; 9: 311
• 22 Tujios SR, Rahnama-Moghadam S, Elmunzer JB. et al. Transpapillary gallbladder stents can stabilize or improve decompensated cirrhosis in patients awaiting liver transplantation. Journal of clinical gastroenterology 2015; 49: 771-777
• 23 Wiesner R, Edwards E, Freeman R. et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology 2003; 124: 91-96