LAUSR

Acute cholecystitis is a common clinical condition that may present with a severity spectrum ranging from mild to severe life-threatening disease. Treatment is initiated with intravenous fluids, antibiotics and analgesia, followed by laparoscopic cholecystectomy performed either early or after an 8-week interval. Cholecystectomy represents definitive therapy but is not appropriate for patients who are unfit for surgery. Approximately 20% will develop more severe disease and fail to respond to medical therapy, and these individuals will require non-surgical gallbladder drainage (GBD). A detailed review of the current non-surgical options for acute cholecystitis management appears in a recent issue of this journal. The choice of drainage technique will often depend on whether drainage is performed as a bridge to surgery (in patients expected to regain surgical fitness) or as definitive therapy in individuals with irreversible severe comorbidities. Other factors affecting the choice of drainage modality include patient factors, the presence of stones, local operator experience, and availability of equipment. Percutaneous transhepatic GBD (PTGBD) is well established, widely available, and technically easy to perform. However, the procedure has some limitations (Table 1) and an overall complication rate of 12%–25%. In addition, long-term placement of an indwelling percutaneous cholecystostomy tube is associated with poor quality of life. The advent of lumen-apposing metal stents (LAMS) has made transmural endoscopic ultrasound-guided GBD (EUS-GBD) a compelling alternative to PTGBD. EUS-GBD is associated with a comparable overall complication rate of 9.9%, but is relatively contraindicated in patients with coagulopathy. EUS-GBD confers the unique advantage of enabling stone removal via the lumen of the LAMS. Saumoy et al. examined the widely held concern that cholecystoduodenal or cholecystogastric fistulae created via EUS-GBD would make interval cholecystectomy more difficult to perform. They found no difference in the rate of successful laparoscopic cholecystectomy following EUS-GBD vs. PTGBD, although the numbers were small. Endoscopic transpapillary GBD (ETGBD), first described by Kozarek in 1984, is another alternative to PTGBD, especially in patients with ascites or coagulopathy. Its adverse effect profile (Table 1) is favorable, and it does not pose an anatomical challenge to interval cholecystectomy. The technique involves the placement of a stent or nasocystic drain across the major papilla. However, cannulation of the cystic duct during endoscopic retrograde cholangiopancreatography can be challenging due to factors such as the inability to locate the cystic duct origin at cholangiography, the presence of Received: February 17, 2020 Revised: March 14, 2020 Accepted: March 15, 2020 Correspondence: Christopher Jen Lock Khor Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore Tel: +65-9636-4349, Fax: +65-6227-3623, E-mail: [email protected] ORCID: https://orcid.org/0000-0002-1409-5691