Post written by Wiriyaporn Ridtitid, MD, Panida Piyachaturawat, MD, and Rungsun Rerknimitr, MD, from the Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross, Bangkok, Thailand.

The focus of our study was to determine the efficacy and safety of single-operator peroral cholangioscopy (SOC) for helping cystic duct cannulation under direct visualization for cystic duct stent placement in moderate to high-surgical risk patients who presented with acute cholecystitis.

Although cholecystectomy is the standard treatment for acute cholecystitis, in real life practice, the challenging scenario is the decision to perform choleystectomy in patients with moderate to high surgical risk. In these particular patients, percutaneous and endoscopic approaches are alternative treatments for gallbladder drainage. When percutaneous and EUS-guided transmural drainage are contraindicated due to ascites, thrombocytopenia, coagulopathy, or inaccessible gallbladder anatomy, endoscopic transpapillary gallbladder stenting (ETGS) or endoscopic naso-gallbladder drainage can serve as a proper alternative treatment strategies.

Based on the previous studies, the technical success rate for ETGS varied from 50% to 96%. The main reason was the inability to identify and access the cystic duct under fluoroscopic guidance. Peroral cholangioscopy (SOC) may be helpful for cystic duct cannulation under direct visualization; however, there have been only a handful of case series reported.

Our study demonstrates that SOC-assisted ETGS can increase the technical success for cystic duct cannulation after failed fluoroscopic guidance. Of 104 acute cholecystitis patients with moderate to high risk who underwent ETGS, 55 patients (53%) had successful endoscopic transpapillary gallbladder stenting under fluoroscopic guidance. Forty-nine patients who had failed fluoroscopic-guided ETGS, underwent additional SOC-assisted ETGS. The overall TSR of ETGS increased from 53% to 75% after additional SOC assistance. Based on our data, SOC-assisted ETGS is beneficial for those with cystic duct orifice located posteromedially or anteromedially, which could not be identified despite significant manipulations including patient or C-arm fluoroscope rotation and those with complete obstruction with no contrast seen in the cystic duct on a balloon-occluded cholangiogram. Moreover, our study evaluated the reasons for failed SOC-assisted cystic duct cannulation which included unstable cholangioscope position, aberrant cystic duct taking off from right intrahepatic duct, and a slit-like cystic duct opening.

We conclude that ETGS should be considered as alternative gallbladder drainage in patients with acute cholecystitis who are not fit for cholecystectomy during an attack of acute cholecystitis. SOC-assisted ETGS can increase the TSR after failed fluoroscopic guidance. However, the details of cost-effectiveness in SOC-assisted ETGS was not part of the present study.

Figure 3. Study scheme: endoscopic transpapillary gallbladder stent placement between January 2015 and June 2019. ETGS, Endoscopic transpapillary gallbladder stenting; SOC, single-operator peroral cholangioscopy.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.