Abstract
Goals:
We evaluated the validity of endoscopic transpapillary gallbladder drainage (ETGBD) as a bridging therapy prior to elective Lap-C for the patients with acute cholecystitis (AC)
Background:
The Tokyo Guidelines 2018 recommend early laparoscopic cholecystectomy (Lap-C) for patients with AC, however, some patients require the preoperative drainage because of inadequate for early Lap-C du to background and comorbidities.
Study:
We performed a retrospective cohort analysis using data from our hospital records from 2018–2021. In total, 71 cases of 61 patients with AC underwent ETGBD.
Results:
The technical success rate was 85.9%. Patients in the failure group had more complicated branching of the cystic duct. The length of time until feeding was started and until WBC levels normalized, and the length of hospital stay were significantly shorter in the success group. The median waiting period for surgery was 39 days in the ETGBD success cases. The median operating time, amount of bleeding, and length of postoperative hospital stay were 134 min, 83.2g, and 4 days, respectively. In patients who underwent Lap-C, the waiting period for surgery and the operating time were similar between the ETGBD success and failure groups. However, the temporary discharge period after drainage and the length of postoperative hospital stay were significantly longer in the patients with ETGBD failure.
Conclusions:
Our study revealed that ETGBD has equivalent efficacy prior to elective Lap-C despite some challenges that lower its success rate. Preoperativ ETGBD can improve patient quality of life by eliminating the need for a drainage tube.
Key Words: Tokyo Guideline 2018, acute cholecystitis, ERCP, ETGBD, Lap-C
The Tokyo Guidelines 2018 (TG18) recommend early laparoscopic cholecystectomy (Lap-C) for patients with acute cholecystitis (AC). These guidelines recommend early Lap-C even for patients with the most severe form of AC (Grade III) as long as the patients have low scores on the American Society of Anesthesiologists physical status classification (ASA-PS) and age-adjusted Charlson comorbidity index (CCI) and the Lap-C is to be performed by a skilled laparoscopic surgeon at an institution that can offer an appropriately high level of care.1
However, some patients cannot undergo Lap-C because of their poor general condition or their specific background or comorbidities. This includes patients who regularly take anticoagulants or who have severe underlying disease.
While awaiting surgery, gallbladder drainage is usually required to stabilize the patient’s general condition. Percutaneous transhepatic gallbladder drainage (PTGBD) was previously recommended as a standard drainage procedure for patients who are at high risk for surgical complications.2–4 However, PTGBD has several potential risks including bleeding, migration of the tube, and lengthening of the hospital stay despite its wide recognition as an established and useful procedure.5 Therefore, the TG18 also recommends endoscopic transpapillary gallbladder drainage (ETGBD) at institutions with physicians skilled in therapeutic endoscopy.1
Many endoscopists have reported that compared with PTGBD, ETGBD may provide effective and safer drainage for patients with AC.6–9 However, widespread use of ETGBD has not yet been adopted by many institutions because of concerns about the greater difficulty and longer procedure time involved.10
In this study, we evaluated ETGBD as a possible alternative to traditional PTGBD for use as a bridging therapy before elective Lap-C.
MATERIALS AND METHODS
Treatment Strategy for AC
Our basic treatment strategy for AC is, in principle, to perform early Lap-C for all patients with Grade I to III AC. In patients with Grade III AC who have extremely severe symptoms such as vital signs indicating shock, drainage should be performed after stabilization of the patient’s general condition. If emergency surgery is not possible because the patient has, for instance, a serious underlying disease or a history of anticoagulant medications, conservative treatment is followed by elective Lap-C. Preoperative drainage should be performed if cholecystitis worsens during the waiting period, if there is a risk of worsening cholecystitis in elderly patients, or if the patient is compromised by a condition such as diabetes mellitus or steroid therapy. In our institution, ETGBD is the first choice for drainage; when ETGBD fails, PTGBD or endoscopic ultrasound-guided gallbladder drainage is the next best option (Fig. 1).
FIGURE 1.
Treatment strategy for patients with acute cholecystitis.
Patient Selection
This was a single-institute retrospective cohort study. Patients who underwent ETGBD at our institution from June 2018 to October 2021 were enrolled in this study. ETGBD was performed as the first-choice therapy for patients with AC who were not eligible for early Lap-C. ETGBD was avoided for patients with malignant tumors in the biliary tract, who were in poor general condition and unable to endure a prolonged procedure, or who had a history of reconstruction of the gastrointestinal tract. All patients provided written informed consent for the endoscopic procedure.
The study was approved by the institutional review board comprising the ethical committee (National Hospital Organization, Tochigi Medical Center, Utsunomiya, Japan; No. 2020-17). This study was conducted in accordance with the Ethical Guidelines for Epidemiological Research in Japan and the Declaration of Helsinki.
Devices for ETGBD
All procedures were conducted under deep sedation. JF-260V or TJF-Q290V (Olympus Corporation, Tokyo, Japan) duodenal fiberscopes were used.
A disposable cannula (PR-V234Q, PR-V233Q Swing Tip; Olympus Corporation) was mostly chosen for cannulation into the major papilla. A guidewire (Pathcourse; Boston Scientific, Natick, MA) was used to allow deep cannulation into the cystic duct (CD). A 5-Fr pigtail endoscopic nasobiliary drainage tube (PBD-V813W-05; Olympus Corporation) was placed in the gallbladder as the drainage tube.
ETGBD Tube Placement
Endoscopic retrograde cholangiopancreatography (ERCP) was performed under sedation with pethidine hydrochloride and flunitrazepam, and the dose was reduced in elderly patients and those in poor general condition. All patients underwent magnetic resonance cholangiopancreatography or contrast-enhanced computed tomography before ERCP in an effort to determine the distribution of the common bile duct (CBD) and CD. The cholangiography was performed by transpapillary cannulation and contrast to confirm the presence or absence of CD contrast. If the CD showed no contrast, intraductal ultrasonography (IDUS) was performed to identify the location of the CD confluence. After insertion of an ETGBD tube into the gallbladder duct, infected bile in the gallbladder was aspirated for culture examination. In principle, the ETGBD tube was pulled out through the nose. The tube was flushed if necessary. In some cases, such as in patients with dementia or delirium, the end of the ETGBD tube was cut within the stomach to avoid self-evulsion by the patient. Flushing management of the ETGBD tube was not possible in the case of intragastric cuts.
Definition of Technical Success and Clinical Efficiency
Technical success was defined as successful placement of the drainage tube into the gallbladder. Clinical efficiency was defined as both improvement of clinical symptoms and normalization of abnormal laboratory findings after the procedure.
Classification of Branching Type and Visualization of the CD
Because ETGBD can sometimes be difficult, the branching of the CD was classified to estimate the expected difficulty. Four groups were defined based on the branching type (Fig. 2). Type I was the simplest branching type, appearing to be almost straight without any bend. Type Δ had a single bend with an obtuse angle. Type N had 2 bends or an acute angle. Type M had more than 3 bends and was expected to be the most complicated. It was expected that type I would be the easiest and type M the most difficult to complete.
FIGURE 2.
Images of the typical branching of the cystic duct classified into 4 types. (A) Type I: the simplest branching type, almost straight without any bend. (B) Type Δ: single bend with an obtuse angle. (C) Type N: 2 bends or with an acute angle. (D) Type M: more than 3 bends, appears most complicated.
We also evaluated whether the CD could be contrasted from the CBD. If no contrast was obtained from the CBD, a cannula was inserted into the bifurcation of the CD, and the possibility of selective contrast from the CBD was also evaluated.
Statistical Analysis
Statistical significance was evaluated between 2 groups of data by the 2-tailed Student’s t-test or the χ 2 test. Multiple comparisons were done by 1-way analysis of variance followed by the Bonferroni test among the 3 groups of AC severity, when comparing every mean with every other mean. The Mann-Whitney U test was used to evaluate ordinal variable data.
Differences were considered statistically significant at P<0.05.
RESULTS
Patients
In total, 266 patients with AC were admitted to our facility from June 2018 to October 2021. Of these, 205 patients did not undergo preoperative drainage. Of these 205 patients, 113 underwent emergency surgery. Of the 266 patients, 61 underwent ETGBD. Of the 61 patients who underwent ETGBD, 47 ultimately underwent surgery (Fig. 3).
FIGURE 3.
Flowchart of treatment for patients with acute cholecystitis.
Patients’ Characteristics
In total, 71 ETGBD procedures were performed for 61 patients (Table 1). Sedation was administered during ERCP, and no patient experienced any adverse events because of the sedative agents. Nine patients underwent ETGBD twice, and one patient underwent ETGBD 3 times. The main reason for multiple procedures was that the ETGBD tube was dislocated and cholecystitis recurred. There were also cases in which the ETGBD tube was reinserted because of lack of clinical efficacy, although the procedure was technically successful. The patients’ ages ranged from 48 to 97 years. Grade I AC was diagnosed in 24 patients (33.8%), Grade II in 42 (59.2%), and Grade III in 5 (7.0%). Anticoagulant drugs were administered in 38 patients (53.5%). Procedure-related complications were encountered in 8 of the 71 procedures (11.3%), including CD injury (4 patients), cholangitis (2 patients), and pancreatitis (2 patients).
TABLE 1.
Patients' Background
| n=71 (Gross) | 71 Cases/61 Patients |
|---|---|
| Age (y) | 83 (48~97) |
| Sex | |
| M:F | 36:35 |
| Severity | |
| Grade I | 24 (33.8%) |
| Grade II | 42 (59.2%) |
| Grade III | 5 (7.0%) |
| Anti-coag. | 38 (53.5%) |
| Op. | 47(77.0%) |
Op indicates operation.
Success Rate of ETGBD
The technical success rate of ETGBD was 85.9%, and the clinical efficiency rate was 93.4% (Table 2). When examined by the severity of AC, there were no differences in the technical success rate or efficiency rate among the different severities of AC.
TABLE 2.
Success Rate of Endoscopic Transpapillary Gallbladder Drainage
| Severity | |||||
|---|---|---|---|---|---|
| Total | Grade I | Grade II | Grade III | ||
| n | 71 | 24 | 42 | 5 | P |
| Age | 83 (48-97) | 83 (48-97) | 83 (61-95) | 85 (41-91) | 0.54 |
| Sex (M:F) | 36:35 | 15:9 | 18:24 | 3:2 | 0.28 |
| BMI | 21.8 | 21.0 | 21.9 | 24.7 | 0.17 |
| Technical success rate | 61 (85.9%) | 21 (87.5%) | 36 (85.7%) | 4 (80%) | 0.40 |
| Efficiency rate | 57 (93.4%) | 18 (85.7%) | 35 (97.2%) | 4 (100%) | 0.48 |
| Procedure time (min) | 42.4 (7-100) | 39.8 (12-80) | 43.1 (7-100) | 48.6 (75-18) | 0.52 |
| Complication | 8 (11.3%) | 2 (8.3%) | 6 (14.3%) | 1 (20%) | 0.69 |
| Anti-coag. | 38 (53.5%) | 14 (58.3%) | 22 (52.4%) | 2 (40%) | 0.74 |
| Op. | 47 (77.0%) | 15 (75.0%) | 28 (77.8%) | 4 (80%) | 0.92 |
BMI indicates body mass index; Op, operation.
Comparison of Technical Success Group with Failure Group
Between the success group and the failure group, there were no significant differences in patient background characteristics such as age, sex, or body mass index (Table 3). The branching type of the CD played an important role in determining the success or failure of this procedure, with a high incidence of type I and Δ branching found in the success group and type N and M in the failure group. The success and failure groups were then evaluated according to whether the CD was visualized. The success group had a higher visualization rate of the CD from CBD injection. Of the 61 procedures in the success group, 38 cases (62.3%) showed positive CD visualization from CBD injection, and 22 (95.7%) of the 23 cases of negative CD visualization from CBD injection turned positive by injection from the bifurcation of the CD. In contrast, only 20% of the failure group showed positive CD visualization from CBD injection, and only 50% of the failure group showed positive CD visualization from CD bifurcation injection.
TABLE 3.
Comparison Between the Endoscopic Transpapillary Gallbladder Drainage Success Group and Failure Group
| Success | Failure | ||
|---|---|---|---|
| n=71 | 61 (85.9%) | 10 (14.1%) | P |
| Age | 81 (48-97) | 86 (82-95) | 0.02 |
| Sex (M:F) | 32:29 | 4:6 | 0.47 |
| Severity (I:II:III) | 21:36:4 | 3:6:1 | 0.99 |
| BMI (kg/m2) | 21.7 | 22.0 | 0.81 |
| Branch type (I:Δ:N:M) | 19:20:20:2 | 0:1:3:6 | 0.02 |
| VCD/CBD | 38 (62.3%) | 2 (20%) | 0.02 |
| VCD/CD | 22 (95.7%) | 4 (50%) | <0.01 |
| CBD ∅ (mm) | 9.0 | 10.4 | 0.16 |
| CBD stone | 17 (27.9%) | 1 (10%) | 0.23 |
| Antibiotics (d) | 3 | 2 | 0.27 |
| WBC | 12,700 | 15,000 | 0.21 |
| CRP (mg/dL) | 13.3 | 20.2 | 0.14 |
| T-Bil (mg/dL) | 1.3 | 1.4 | 0.99 |
| Alb (mg/dL) | 3.3 | 2.6 | <0.01 |
| Hb (g/dL) | 12.6 | 11.6 | 0.36 |
| PT% | 76.6 | 86.6 | 0.90 |
| Cr. (mg/dL) | 0.8 | 1.0 | 0.59 |
| Complication | 6 (9.8%) | 3 (30%) | 0.08 |
| Procedure time (min) | 37.6 | 71.6 | <0.01 |
| Time to start feeding (d) | 5 | 7 | 0.01 |
| Time to normalize WBC (d) | 4 | 10 | <0.01 |
| Length of stay (d) | 8 | 22 | <0.01 |
| ASA | 2 (1-4) | 3 (2-4) | 0.03 |
| CCI | 6 (2-9) | 8 (6-9) | <0.01 |
| Anti-Coag. | 32 (52.7%) | 6 (60%) | 0.74 |
| Op. | 39 (70.1%) | 8 (80%) | 0.99 |
Alb indicates albumin; ASA, American Society of Anesthesia physical status classification; BMI, body mass index; CBD, common bile duct; CCI, Charlson comorbidity index; Cr, creatinine; CRP, C-reactive protein; Hb, hemoglobin; Op, operation; PT, prothrombin time; T-Bil, total bilirubin; VCD/CBD, visualization of the cystic duct from CBD; VCD/CD, visualization of the cystic duct from cystic duct; WBC, white blood cell.
Antibiotics, duration of antibiotic use until ETGBD.
The procedure time, days to start feeding, and days until white blood cell count normalization were shorter in patients in the success group. These results suggest that the outcome of drainage was better in the success group than in the failure group, in which the patients mostly underwent PTGBD as an alternative drainage procedure. The ASA-PS and CCI scores were significantly higher in the failure group than in the success group.
Comparison of Severity
There were no significant differences in the CD branching type, the diameter of the CBD, or the presence of CBD stones among the 3 severities of AC (Table 4). The white blood cell count tended to be higher in severe cases, reflecting the severity of cholecystitis. However, there was no significant difference in the outcome of ETGBD in severe cases; therefore, the ETGBD procedure seemed to be equally effective for all severities of AC.
TABLE 4.
Comparison Between the 3 Grades of Severity
| Severity | |||||
|---|---|---|---|---|---|
| Total | Grade I | Grade II | Grade III | ||
| n | 71 | 24 | 42 | 5 | P |
| Branching type | |||||
| (I,Δ:N,M) | 40:31 | 14:10 | 24:18 | 3:2 | 0.94 |
| CBD ∅ (mm) | 9.2 | 9.7 | 9.0 | 7.6 | 0.28 |
| CBD stone | 18 (25.4%) | 5 (20.8%) | 13 (31.0%) | 0 | 0.27 |
| WBC | 13,200 | 10,200 | 14,900 | 23,200 | <0.01 |
| CRP | 14.3 | 12.5 | 16.1 | 18 | 0.54 |
| T-Bil | 1.3 | 1.3 | 1.3 | 1.7 | 0.95 |
| Alb | 3.1 | 3.3 | 3.1 | 3.4 | 0.50 |
| Hb | 12.7 | 12.3 | 12.8 | 14.9 | 0.34 |
| PT% | 76.8 | 85.0 | 76.3 | 66.5 | 0.87 |
| Cr. | 0.8 | 0.8 | 0.8 | 1.1 | 0.22 |
| Start to feeding (d) | 5 (1-14) | 4 (1-12) | 5 (1-14) | 4 (3-7) | 0.59 |
| Normalize WBC (d) | 4 (1-28) | 2 (1-14) | 5 (1-28) | 6 (5-15) | 0.08 |
| Length of stay (d) | 9 (2-55) | 11 (1-24) | 9 (2-55) | 8 (6-20) | 0.78 |
| Duration of ETGBD (d) | 16 (2-235) | 12 (2-235) | 16 (2-70) | 16 (6—38) | 0.39 |
| ASA | 2 (1-4) | 2 (1-4) | 2 (1-4) | 2 (1-3) | 0.24 |
| CCI | 7 (2-9) | 6 (2-9) | 6 (3-9) | 6 (3-7) | 0.61 |
Alb indicates albumin; ASA, American Society of Anesthesia physical status classification; CBD, common bile duct; CCI, Charlson comorbidity index; Cr, creatinine; CRP, C-reactive protein; ETGBD, endoscopic transpapillary gallbladder drainage; Hb, hemoglobin; PT, prothrombin time; T-Bil, total bilirubin; WBC, white blood cell.
Comparison Between Success and Failure of ETGBD in Patients who Underwent Surgery
We compared patients for whom ETGBD was and was not successful who then underwent Lap-C (Table 5). There was no difference in the patients’ background characteristics except age. The number of days of temporary discharge was significantly higher in the patients in the failure group who underwent PTGBD to provide alternative preoperative drainage. The ASA-PS and CCI scores were higher in the failure group, but there was no difference in the outcome of surgery between the 2 groups. Patients in the failure group had a longer hospital stay after surgery.
TABLE 5.
Comparison Between Groups With/Without Success of ETGBD in Surgery Cases
| Success | Failure | ||
|---|---|---|---|
| n=61 (patients) | 39 | 8 | P |
| Age | 81 (49-93) | 85 (82-92) | 0.02 |
| Sex (M:F) | 21:18 | 4:4 | 0.99 |
| Severity (I:II:III) | 12:24:3 | 3:4:1 | 0.99 |
| Temporally discharge (d) | 8 (2-28) | 20 (18-26) | <0.01 |
| Waiting for surgery (d) | 39 (2-94) | 42 (29-93) | 0.42 |
| Operation time (min) | 134 (53-236) | 142 (80-236) | 0.66 |
| Blood loss (g) | 83.2 (3-374) | 32.4 (2-80) | 0.22 |
| How the CD was handled (clip or ligation) | 29:9 | 6:2 | 0.99 |
| Conversion to laparotomy | 0 | 0 | NA |
| ASA | 2 (1-3) | 3 (2-3) | 0.03 |
| CCI | 6 (2-8) | 8 (6-9) | <0.01 |
| Length of stay after Op. | 4 (3-11) | 9 (7-16) | <0.01 |
ASA indicates American Society of Anesthesia physical status classification; CCI, Charlson comorbidity index; CD, cystic duct; ETGBD, endoscopic transpapillary gallbladder drainage; Op, operation.
Comparison Between Patients who Did and Did Not Undergo Surgery Among ETGBD Cases
We examined the differences in the patients’ background characteristics between those who did and did not undergo surgery in the ETGBD success group (Table 6). The nonoperative group tended to be older and to spend a longer time in hospital. There were no differences in the complication rate or efficacy of preoperative gallbladder drainage between the 2 groups, but the nonoperative group had a longer period of ETGBD tube placement, higher ASA-PS and CCI scores, and a higher rate of severe comorbidities.
TABLE 6.
Comparison Between Groups With/Without Surgery in ETGBD Success Cases
| OPE | Non-OPE | ||
|---|---|---|---|
| n=51 (patients) | 39 | 12 | P |
| Age | 81 (49-93) | 87 (48-97) | <0.01 |
| Sex (M:F) | 21:18 | 6:6 | 0.99 |
| BMI | 22.7 | 20.2 | 0.11 |
| Severity (I:II:III) | 12:24:3 | 4:7:1 | 0.99 |
| Complication of ERCP | 4 (9.8%) | 2 (16.7%) | 0.64 |
| Duration of ETGBD (d) | 16 (2-57) | 52 (5-235) | 0.03 |
| Start to feeding (d) | 4 (1-14) | 5 (2-10) | 0.14 |
| Normalize WBC (d) | 4 (1-14) | 6 (1-15) | 0.12 |
| Length of stay (d) | 8 (2-28) | 11 (4-17) | 0.13 |
| Anit-Coag. | 19 (50%) | 9 (75%) | 0.13 |
| ASA | 2 (1-3) | 3 (2-4) | <0.01 |
| CCI | 6 (2-8) | 7 (6-9) | <0.01 |
| Comorbidity (none:mild:mod:severe) |
4:19:13:3 | 0:3:6:3 | 0.03 |
ASA indicates American Society of Anesthesia physical status classification; BMI, body mass index; CCI, Charlson comorbidity index; ERCP, endoscopic retrograde cholangiopancreatography; ETGBD, endoscopic transpapillary gallbladder drainage; OPE, operation; WBC, white blood cell.
DISCUSSION
Our data revealed the efficiency of ETGBD as an alternative preoperative drainage procedure for patients with AC undergoing elective Lap-C.
The success rate of ETGBD at our institution was 86%, which is comparable with previous reports.10–14 The incidence of ETGBD-related complications was 11.3%. In previous reports, post-ETGBD adverse events reportedly occurred in 0% to 14% of patients, which is similar to our results.15,16 Our results are also comparable with those of PTGBD, which has been reported to cause complications such as catheter displacement in 5.9% to 16.1% of patients.17–20 In addition, when ETGBD fails, we can still choose alternative treatment methods such as endoscopic ultrasound-guided gallbladder drainage and PTGBD. Therefore, the complication rate of ETGBD is well within the acceptable range.
There were no differences in the technical success rate or efficiency rate among the different severities of AC. There were also no differences in the procedure time or complication rate among the severities. Our study included 24 (33.8%) patients with Grade I AC. According to the TG18, early Lap-C is indicated for patients with Grade I AC. However, the majority of our patients with Grade I AC were at high risk for complications of emergency surgery because they were taking anticoagulants (58.3%), were very elderly, had high ASA-PS or CCI scores, or had serious underlying diseases. Therefore, emergency surgery was not an option for these patients, and preoperative drainage was unavoidable.
These results indicate that ETGBD is effective for all severities of AC, from mild to severe. There was no difference in surgical outcomes between patients who underwent successful and failed ETGBD. However, patients who underwent failed ETGBD had a longer hospital stay, regardless of whether they underwent surgery.
Several reports have evaluated the factors that increase the success rate of ETGBD. The gallbladder wall thickness, short-axis length of the gallbladder, age, presence of CBD stones, dilation of the CBD, and CD direction are considered potential predictive factors.10–12 In this study, we focused not only on the CD direction but also on the type of branching of the CD. When the branching was divided into 4 types, the success rate decreased as the branching became more complex. In the I/Δ types, ETGBD was successful in 39 of 40 patients (97.5%), whereas in the N/M type, ETGBD was successful in only 22 of 31 patients (71.0%) (Table 3). Therefore, the type of branching of the CD seems to be a predictive factor for success. Before performing ETGBD, the branching of the CD should be evaluated by magnetic resonance cholangiopancreatography. If a complicated branching type is suspected, it may be necessary to pursue IDUS or prepare various types of cannulas and guidewires.
Our results indicate that positive or negative visualization of the CD also plays a role in ETGBD success. In approximately 38% of the successful cases, the CD was not visualized from the CBD. In contrast, the CD was visualized from the CD bifurcation in most of the successful cases and was not visualized in half of the failure cases. This result indicates that even if the CD was not visualized from the CBD, the probability of success is high; if the CD bifurcation is identified by IDUS, then CD visualization from the bifurcation can be obtained and the contrast agent can be successfully injected into the gallbladder. Conversely, cases in which the CD is not visualized even by injection from the bifurcation of the CD are unlikely to be successful.
It is important to understand the advantages and disadvantages of ETGBD for preoperative drainage and to perform it only in appropriate cases. The advantages of ETGBD are as follows: (1) its efficiency is comparable with that of conventional PTGBD. (2) Equivalent effects can be achieved in patients with all severities of AC, from Grade I to III. (3) ETGBD can potentially contribute to improved quality of life and a reduction in the length of hospital stay because a tube does not need to be managed outside the body. (4) The ETGBD tube can be removed whenever the cholecystitis improves, whereas removal of the PTGBD tube must be performed after 3 to 4 weeks because it penetrates the liver. (5) ETGBD carries no risk of bleeding. By contrast, the disadvantages are as follows: (1) the degree of difficulty is high. (2) A longer procedure time is required. (3) There is a potential risk of perforation and bile duct injury.
ETGBD must be performed carefully, particularly in elderly patients. It is important to understand the advantages and disadvantages of ETGBD, and careful attention should be paid to patient selection.
We evaluated and compared these results with those from our previous report regarding the impact of PTGBD on elective surgeries for AC (Table 7).21 There were no significant differences in the patients’ background characteristics or severities of AC. Furthermore, although there was no significant difference in the surgical outcome itself, the PTGBD group tended to have a longer hospital stay, both temporarily before surgery and postoperatively.
TABLE 7.
Comparison Between ETGBD and PTGBD Before Elective Surgery for AC
| ETGBD | PTGBD17 | |
|---|---|---|
| n | 39 | 17 |
| Age | 81 (49-93) | 75 |
| Sex (M:F) | 21:18 | 9:8 |
| Severity (I:II:III) | 12:214:3 | 0:12:5 |
| BMI | 22.7 | 22 |
| WBC | 13,000 | 13,460 |
| CRP (mg/dL) | 13.3 | 21.0 |
| T-Bil (mg/dL) | 1.5 | 1.0 |
| Alb (mg/dL) | 3.3 | 2.9 |
| Hb (g/dL) | 13.1 | 13.0 |
| PT% | 80.0 | 87.0 |
| Cr. (mg/dL) | 0.80 | 0.89 |
| Start to feeding (d) | 4 | 6 |
| Temporally discharge (d) | 8 | 22 |
| Waiting for surgery (d) | 39 | 42 |
| Operation time (min) | 134 | 125.3 |
| Blood loss (g) | 83.2 | 53.2 |
| Complications | 0 | 0 |
| Conversion to laparotomy | 0 | 0 |
| ASA | 2 (1-3) | 3 (1-3) |
| Length of stay after Op. | 4 (3-11) | 18.8 (7-16) |
AC indicates acute cholecystitis; Alb, albumin; ASA, American Society of Anesthesia physical status classification; BMI, body mass index; Cr, creatinine; CRP, C-reactive protein; ETGBD, endoscopic transpapillary gallbladder drainage; Hb, hemoglobin; Op, operation; PT, prothrombin time; PTGBD, percutaneous transhepatic gallbladder drainage; T-Bil, total bilirubin; WBC, white blood cell.
Early Lap-C is undoubtedly the most desirable treatment for AC in terms of the shorter hospital stay and lower medical costs. However, an elective procedure is sometimes necessary for elderly patients, patients with severe underlying comorbidities, and patients with serious general conditions.
PTGBD has been commonly used as a preoperative drainage method for such patients. However, PTGBD has a high risk of complications such as catheter displacement, catheter migration, and bleeding from the liver. Therefore, it is necessary to explore alternative methods. Our results indicate that ETGBD may be a candidate alternative.
This study had some limitations. The main limitation is that the study evaluated a series of treatment experiences at only one institution. A prospective randomized clinical trial should be performed for comparison with a PTGBD-treated group. However, it is clear that ETGBD is at least as effective as PTGBD and can be an alternative to PTGBD as a bridging therapy before elective Lap-C.
CONCLUSIONS
ETGBD has the potential to replace conventional PTGBD as a first-line procedure for patients who are not candidates for early Lap-C or who undergo delayed surgery.
Footnotes
K.S. was responsible for the study design and planning, performing the ETGBD procedure and the surgery (Lap-C), analyzing the data, and writing the article. H.N., E.N., N.Y., .K., and T.H. performed the ETGBD procedures. K.S., Y.Y., and K.O. participated in the data collection and analysis. A.T. formulated, designed, and conducted the entirety of the study.
The authors declare that they have nothing to disclose.
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