Advanced gallbladder interventions after EUS-guided gallbladder drainage

ARTICLE IN PRESS Techniques in Gastrointestinal Endoscopy 000 (2019) 150629

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Advanced gallbladder interventions after EUS-guided gallbladder drainage Shannon Melissa Chan, MBChB, FRCSEd, FHKAM (Surgery)a,b, Anthony Yuen Bun Teoh, MBChB, FRCSEd, FHKAM (Surgery)a,b*, Philip Wai Yan Chiu, MD, MBChB, FRCSEd, FHKAM (Surgery)a,b, Enders Kwok Wai Ng, MD, MBChB, FRCSEd, FHKAM (Surgery)a,b, James Yun Wong Lau, MD, FRCSEd, FHKAM (Surgery)a,b a b

Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China

A R T I C L E

I N F O

Article history: Received 1 May 2019 Accepted 14 June 2019 Keywords: Cholecystoscopy Gallbladder interventions Endoscopic ultrasound guided gallbladder drainage EGBD

A B S T R A C T

The development of EUS-guided gallbladder drainage (EGBD) with a lumen-apposing stent has made endoscopic assessment and advanced gallbladder interventions via the stent possible. This is a review article on the different interventions reported in literature. Diagnostic procedures with magnifying endoscopy, endocytoscopy, endoscopic ultrasound, and confocal laser microscopy for polyps and carcinoma of gallbladder have been reported. Therapeutic interventions for stone removal with snare, Roth net, mechanical basket lithotripsy, or laser lithotripsy. Polypectomy can also be performed with snare. With EGBD becoming more popular, more upcoming new interventions may be feasible. © 2019 Elsevier Inc. All rights reserved.

1. Introduction According to the Tokyo Guidelines 2018 for management of acute cholecystitis, percutaneous transhepatic gallbladder drainage is recommended as a standard drainage method of surgically high-risk patients with acute cholecystitis [1]. However, endoscopic transpapillary gallbladder drainage and endoscopic ultrasound-guided gallbladder drainage (EGBD) could be considered in high volume institutes when performed by skilled endoscopists. EGBD has been gaining popularity especially with the emergence of lumen apposing stents (LAMS) [2-7]. With the development of EGBD with lumen apposing stent (LAMS), gallbladder access via the stent was made possible. Through this access, advanced endoscopic evaluation and therapeutic interventions can be performed. 2. Indications The main aim of cholecystoscopy is for clearance of gallstones so that the lumen apposing metal stent can be removed. However, there Conflicts of interest: None declared. This study was not supported by any research grant. *Corresponding author. E-mail address: [email protected] (A.Y.B. Teoh). https://doi.org/10.1016/j.tgie.2019.150629 1096-2883/© 2019 Elsevier Inc. All rights reserved.

is currently no consensus as to whether the LAMS should be removed or not. The main concerns about keeping the LAMS long term are stent erosion causing bleeding and stent migration. The counter argument is the rate of recurrent cholecystitis after removal of the LAMS. In a cohort of 56 patients, Choi et al described 2 cases of complete stent migration at 170 and 303 days after stent placement and recurrent cholecystitis in 2 patients as a result of stent dysfunction [8]. Walter et al, however, reported no adverse event from long term placement of LAMS in 15/30 patients in a mean duration of 364 days, suggesting that leaving the stents in situ may be considered an alternative treatment option which avoids the risk and discomfort associated with a repeat procedure for stent removal [6]. In the case-matched cohort by Teoh et al, the standard protocol was for cholecystoscopy 3 months after the procedure for stone clearance. The procedure was repeated until all stones were cleared and the metal stent removed. The stents were kept in situ if the patient refused or was deemed unfit to proceed to further interventions [7]. A total of 17 out of 59 patients had their stents removed and the rate of recurrent cholecystitis was 0%. In another study by Kamata et al which assessed the long-term outcomes of self-expandable metal stents after EGBD, stent removal without stent replacement was carried out in 8 patients and there were no recurrent acute cholecystitis in a mean follow-up of 304 days [5]. Therefore the authors concluded that removal of stent is recommended as it would avoid stent migration and recurrence of acute

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S.M. Chan et al. / Techniques in Gastrointestinal Endoscopy 00 (2019) 150629

cholecystitis due to food impaction. In a recent update, the recommendation was that for patients with an expected short-term survival, permanent stent placement may be suitable in order to avoid reintervention and recurrence of acute cholecystitis. In patients with longer expected survival, stent removal may be more suitable to reduce stent-related complications [9]. 3. Techniques and equipment With LAMS inserted for EGBD with a cholecystogastric or cholecystoduodenal tract formed, a standard forward viewing endoscope can be inserted via the tract into the gallbladder. The size of the endoscope depends on the size of LAMS inserted. Reported LAMS used for gallbladder drainage are the AXIOS stent (Boston Scientific Corporation, Malborough, MA; 10 mm, 15 mm) [7], the SPAXUS stent (Niti-S, Taewoong Medical, South Korea; 10 mm, 16 mm) [10] and the Microtech stent (Microtech(Nanjing) Co. Ltd., China; 10 mm) [11]. All peroral cholecystoscopies should be performed under carbon dioxide insufflation with a standard forward viewing endoscope preferably equipped with water-jet irrigation. For diagnostic purposes, a magnifying endoscope with short cap can be used. Endocystoscopy and confocal laser microscopy can also be performed. To detect the depth of involvement of any lesions, endoscopic ultrasound (EUS) with miniprobe may be used. Biopsies can also be taken for histology. In the presence of gallstones, different equipment can be used to remove the stones including rat-tooth or alligator forceps, snares, baskets, or Roth nets (Figure 1). For larger stones which preclude removal, mechanical basket lithotripsy or laser lithotripsy could be used (Figure 2a and b). For gallbladder polyps, these can be removed with cold biopsy or snare polypectomy. Cholecystogram and/or cholangiogram can also be performed with fluoroscopic guidance. 4. Current literature available To date, only 2 case series have been published on per oral cholecystoscopy. In a retrospective cohort from Hong Kong consisting of 25 patients, 29 cholecystoscopies were performed [12]. Cholecystoscopy was performed 1-3 months after the initial LAMS placement according to protocol. Six out of 25 (24%) of the stents were inserted via the antrum and the remainder were inserted via the duodenum. Technical success rate was 93.1%. One procedure failed due to acute angulation of the stent, and a second failed due to obstruction by a large gallstone. In that study, magnifying endoscopy was performed in 10 patients, confocal endomicroscopy and EUS in 1 patient, and endocytoscopy in another. All of the 10 magnifying endoscopies

Fig. 1. Removal of gallstones with snare.

Fig. 2. (a) Two-cm gallstone requiring laser lithotripsy. (b) After laser lithotripsy, stone fragments removed with alligator forceps.

performed showed endoscopic features of inflammation that were confirmed with histology. Endocytoscopy was performed in 1 case and demonstrated a layer of regular columnar cells with finger-like projections compatible with normal gallbladder mucosa. In another case where a highly suspicious polypoid growth was detected, magnifying endoscopy showed malignant features with EUS showing suspicious involvement of the muscularis propria, and final histology confirmed adenocarcinoma of the gallbladder. Gallstones were completely cleared in 22 patients. The overall stone clearance rate was 88% after a mean (SD) number of 1.25 (0.46) sessions of cholecystoscopy. One patient had a 2 cm gallstone with holmium laser lithotripsy (VersaPulse PowerSuite; UHS, Minneapolis, MN) performed with complete stone removal. Three patients had the gallstones removed with a Roth net (US Endoscopy, Mentor, Ohio), 1 with irrigation and suction and 1 with basket (22Q; Olympus Medical, Tokyo, Japan). Cholecystography was performed in 11 patients and all were successful. One case demonstrated a common bile duct stone which was removed with endoscopic retrograde pancreatography. Polypectomy was performed with snare in 1 patient (Olympus Medical, Tokyo, Japan). The LAMSs were removed with rat tooth forceps without difficulty. In another retrospective cohort by Ge et al consisted of 7 patients [11]. All LAMS were placed transgastrically. Cholecystoscopies were performed 1-2 weeks after initial LAMS placement. Stone baskets were used to retrieve stones. Polypectomy and endoscopic mucosal resection techniques were used with snare or argon plasma coagulation. After the stones were cleared, the stents were removed and an endoscopic nasobiliary drainage (ENBD) was placed. 24 hours later, radiography would be performed to check for stone clearance before the catheter was removed. A forward viewing endoscopy was used to

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check the healing of the fistula 24 hours after removal of the ENBD. If the fistula had closed, the patient can be resumed on normal diet. If not, it was closed by the OTSC device (Ovesco Endoscopy AG, Tuebingen, Germany). Seven patients had cholecystoscopies performed and 5 had a concomitant endoscopic retrograde pancreatography performed. Stones were cleared in all patients. The fistula spontaneously closed in 6 patients 24 hours after removal of the ENBD. In 1 patient, the fistula failed to close and had food impaction in the gallbladder. The fistula was closed with OTSC after food residue was cleared.

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optimal way to manage these cases should be patient oriented and would require further studies to investigate. 6. Conclusions Advanced gallbladder intervention was made feasible with LAMS after EGBD. Both diagnostic and therapeutic interventions are now possible. This opens up an array of exciting possibilities that can be performed. The clinical indications and long-term efficacy, though has yet to be determined with more studies.

5. Discussion

References

Cholecystolithiasis has been a long-standing clinical problem. For decades, access to the gallbladder has only been achieved surgically with cholecystectomy and still remains the gold standard of treatment for patients with acute cholecystitis who are surgically fit [13]. For patients who are not surgical candidates, percutaneous cholecystotomy is performed. Access to the gallbladder was achieved with percutaneous cholecystoscopy after serial tract dilatation after percutaneous cholecystotomy. Percutaneous cholecystolithotomy (PCCL) [14], extracorporeal shock wave lithotripsy [15] and percutaneous gallstone dissolution with methyl tert-butyl ether [16] have been performed in the past but have fallen out of favour due to high stone recurrence rates. This is also a cumbersome procedure where serial dilatation is required before adequate access to the gallbladder is gained, leading to patient discomfort. Endoscopic transpapillary gallbladder drainages has also been performed as an alternative [17]. With EGBD performed with LAMS, it creates a portal to the gallbladder. This allows access for therapeutic endoscopes and instruments. Numerous procedures that can be performed safely within the gallbladder, both diagnostic and therapeutic. Stone clearance can be achieved with simply irrigation, removal by snare and Roth net. Larger stone can be fragmented into smaller pieces and removed. Although available literature is limited, it seemed that these procedures are safe and effective. One of the concerns though, is on long term stone recurrence. Previous reports showed that with PCCL, the stone recurrence rate was 9.8% in 14 months, and up to 60%-80% in 10 years [14,16]. Donald et al investigated on the long term outcomes of stone recurrence after PCCL [18]. The study showed that 31 out of 100 (31%) patients had stone recurrence detected on scheduled ultrasound scan. Seventeen of 31 (54.8%) remained asymptomatic and 8 out of 31 (25.8%) required cholecystectomy. The cholecystectomies encountered adhesions during laparoscopy but none required conversion to open. For now, the indication for EGBD remains for surgically unfit patient. For this group of patients, the life expectancy is expected to be short. Based on this, even the gallstones recurred, it is likely they would remain asymptomatic. In patients whose comorbidities may improve, more aggressive stone clearance is required. The rationale is 2-fold. First, is to prevent further stone-related complications. Second is for removal of the double-flanged metal stent to avoid stent related complications such as impingement, erosion, and bleeding. In these cases, the insertion of a double pigtail catheter after removal of LAMS may be able to prevent recurrent cholecystitis or facilitate salvage of the fistulous tract when cholecystitis recurs. The

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