Post written by Mihai Rimbaş, MD, PhD, and Alberto Larghi, MD, PhD, from the Gastroenterology Department, Colentina Clinical Hospital; the Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania; the Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS; and the Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy.

We aimed to identify the next logical patient population in which EUS-guided gallbladder drainage (EUS-GBD) using lumen-apposing metal stents (LAMS) could be indicated.

EUS-GBD is becoming the treatment of choice for patients with acute cholecystitis (AC) at high surgical risk over percutaneous drainage. The search for additional patient populations to which this treatment can be applied seems warranted.

In the last year, 2 published studies strongly impacted the strength of evidence behind the utilization of EUS-GBD. A RTC clearly reported the overwhelming superiority of EUS-GBD over percutaneous GBD for treatment of patients with AC at high surgical risk in terms of significant reduction in 1-month and 1-year adverse event rates. A propensity score matching study comparing EUS-GBD in high-risk surgical patients (few without AC) with laparoscopic cholecystectomy performed in non-high surgical risk patients reported comparable results suggesting EUS-GBD as a possible alternative even in patients who may be fit for surgery.

These studies stimulated us to search for additional patient populations in which EUS-GBD could be indicated. Conversion of laparoscopic to open cholecystectomy can be associated, especially in frail elderly patients, with an increase in adverse events, costs, length of hospital stay, readmission, and mortality rates. Many individual variables have been found to be associated with an increased risk of conversion, but no one has ever been incorporated into clinical practice. Conversely, a recently published prediction model developed by Goonawardena and colleagues identified previous upper abdominal surgery, obesity, choledocholithiasis, impacted stone at gallbladder neck, and gallbladder wall thickness as preoperative risk factors, based on which graphic nomograms were developed as practical tools for individual risk stratification to predict conversion to open surgery. An association of more than 4 of these risk factors or at least 3 including a thickened gallbladder wall could reliably identify patients with a probability of conversion higher than 80%. This risk stratification model opens a window for alternative treatment approaches such as EUS-GBD that has the advantage to be potentially followed by intra-cholecystic endoscopic interventions, when needed. Properly designed studies to evaluate the benefit of EUS-GBD in patients above described are needed.

 

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