Post written by Giuseppe Vanella, MD, from the Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.
In this video case series, we discuss how endoscopic treatment of acute cholecystitis (AC) can improve the management of patients in a multidisciplinary cancer institute.
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is emerging as the best treatment for AC in unfit-for-surgery patients. Using lumen-apposing metal stents (LAMSs), the large-caliber communication between the gallbladder and the gastrointestinal tract allows effective drainage in the acute phase, but also subsequent endoscopic access to the gallbladder (the so-called peroral endoscopic cholecystoscopy [POEC]) with eventual complete stone clearance, offering a potentially “curative” solution for frailer patients.
This is especially valuable in patients with malignant neoplasia, as a prompt, effective, and minimally invasive treatment of AC allows rapid initiation or resumption of oncological treatments with reduced discomfort and need for reinterventions compared to the most-used alternative, which is percutaneous drainage (PT-GBD).
We felt it was important to share our experience in this field, as we have nowadays randomized and controlled evidence showing the advantages of EUS-GBD over PT-GBD, but scantier data regarding the follow-up of these patients, especially in the oncological setting. Literature regarding subsequent POEC is mainly composed of retrospective reports, although in this article we report the outcomes of prospectively included patients treated in a standardized fashion with a scheduled 4-week procedure aimed at complete stone clearance and stent exchange (from LAMS to double-pigtail plastic stent).
We also discuss how the first procedure (drainage) and the second procedure (POEC and stent removal) were embedded in the general management plan of these patients with no or minimal chemotherapy discontinuation.
Apart from reporting the cases and their outcomes with detailed iconography and prospective follow-up, the article also discusses several technical variables, from stent choice to the site of drainage, the placement of coaxial double-pigtail stents, and a detailed description of tools for subsequent stone removal, in light of our experience and the best available preliminary evidence.
In conclusion, our experience suggests that gallbladder drainage and subsequent endoscopic cholecystoscopy might reduce the time of chemotherapy in neoplastic patients because of a fast AC resolution, impact of the procedures (avoiding the need for percutaneous catheters), and risk of AC recurrence. This small prospective series promotes larger investigation of this minimally invasive management of AC in frailer patients for whom surgery is undesirable, especially those whose prognosis strongly depends on chemotherapy continuity.
Placement of a coaxial double-pigtail silicon plastic stent inside the lumen-apposing metal stent: radioscopic (A) and endoscopic (B) appearance.
Read the full article online.
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