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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
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Letter to the Editor

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Endoscopic Techniques for Gallbladder Drainage: Never without My Endoscopic Ultrasound

Gianmarco Marocchi , Andrea Lisotti , and Pietro Fusaroli

Gastrointestinal Unit, Department of Medical and Surgical Sciences, Hospital of Imola, University of Bologna, Imola, Italy

Correspondence to:Gianmarco Marocchi
ORCID https://orcid.org/0000-0001-9925-3486
E-mail gianmarco.marocchi2@gmail.com

Received: February 14, 2021; Accepted: February 22, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut and Liver 2021; 15(4): 634-636

Published online July 15, 2021 https://doi.org/10.5009/gnl210074

Copyright © Gut and Liver.

To the Editor:

We read with great interest the article by Yoshida et al.1 published online in January 2021, that described cholangioscopic assistance for endoscopic transpapillary gallbladder drainage (ETGBD) in 101 high-risk surgical patients with acute cholecystitis. The authors reported that the optional use of cholangioscopy could lead to a significantly higher technical success rate than the use of conventional ETGBD alone (94.1% vs 72%). A 4-step classification was also developed to categorize the factors that could complicate ETGBD. The authors conclude that the application of cholangioscopic assistance in a coordinated manner, based on the 4-step classification, represents a valid strategy for improving the success rate of ETGBD, in particular in the early stages, when there is a greater probability of technical failure. However, as stated by the authors, ETGBD is a challenging procedure that requires advanced endoscopic techniques and carries the possibility of adverse events, such as post-ERCP pancreatitis. Furthermore, advancing the guidewire in the presence of tortuosity of the cystic duct remains an unsolved issue, even with cholangioscopic assistance.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) represents a valid alternative that can overcome the abovementioned problems. EUS-GBD is a well described procedure in high-risk surgical patients with acute cholecystitis, either as a bridge to surgery or as a definitive therapy.2-6 Two recent systematic reviews and meta-analyses reported a significantly higher clinical success rate with EUS-GBD than with ETGBD7 and percutaneous gallbladder drainage,8 with similar rates of adverse events between the procedures. In the past year, faced with issues related to the COVID-19 (coronavirus disease 2019) pandemic, such as a shortage of operating rooms and intensive care unit beds, our group suggested that EUS-GBD should be considered the intervention of choice in patients with acute cholecystitis to obtain a definitive treatment and allow rapid patient discharge.9 We reported the case of an 80-year-old woman with sepsis due to acute cholecystitis that was successfully managed outside the operating room and intensive care unit. In that patient, gallbladder drainage was achieved by the EUS-guided placement of a 10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS). The procedure lasted 20 minutes and no adverse events occurred. The patient was discharged 4 hours later.10 Furthermore, we previously reported that in most cases, EUS-GBD could be performed without general anesthesia, avoiding intensive care unit admission and reducing the occurrence of anesthesiology-related adverse events.11,12 Adverse effects of EUS-GBD, such as bleeding and perforation, have been described in a small percentage of cases.8 In our experience, a conspicuous bleeding due to the puncture of a gallbladder wall arteriole following the insertion of a LAMS was successfully rescued by the deployment of a second LAMS close to the bleeding point, leading to mechanical hemostasis.13 In that case, contrast-enhanced harmonic EUS (CH-EUS) played a central role. Although CH-EUS has already been shown to be a useful tool in the diagnostic phase,14-16 increasing exexperience with CH-EUS guided therapeutic interventions is being reported. In the aforementioned case, CH-EUS was crucial for the identification of the feeding vessel, allowing the deployment of the second LAMS in a targeted manner. Furthermore, the absence of spreading of the contrast dye demonstrated the success of the rescue strategy.

As was brilliantly demonstrated by Yoshida et al.,1 some technological developments can be adopted to simplify complex interventional procedures. In addition to the introduction of dedicated devices for EUS-guided drainage that allow the spread of pancreatic fluid collection or biliary drainage,17-19 it was found that the use of a single-operator digital cholangioscope could improve the technical and clinical outcomes of ETGBD. Finally, several drainage strategies are available for use in high-risk surgical patients with acute cholecystitis; in our opinion, EUS-GBD seems to offer some marked advantages over ETGBD and percutaneous gallbladder drainage,20,21 providing a definitive therapy with high rates of technical and clinical success while requiring less anesthesia and a shorter duration of hospitalization.


No potential conflict of interest relevant to this article was reported.

  1. Yoshida M, Naitoh I, Hayashi K, et al. Four-step classification of endoscopic transpapillary gallbladder drainage and the practical efficacy of cholangioscopic assistance. Gut Liver 2021;15:476-485.
    Pubmed KoreaMed CrossRef
  2. Itoi T, Binmoeller KF, Shah J, et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012;75:870-876.
    Pubmed CrossRef
  3. Dollhopf M, Larghi A, Will U, et al. EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device. Gastrointest Endosc 2017;86:636-643.
    Pubmed CrossRef
  4. Fusaroli P, Jenssen C, Hocke M, et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V-EUS-Guided Therapeutic Interventions (short version). Ultraschall Med 2016;37:412-420.
    Pubmed CrossRef
  5. Mori Y, Itoi T, Baron TH, et al. Tokyo guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018;25:87-95.
    Pubmed CrossRef
  6. Fusaroli P, Serrani M, Lisotti A, D'Ercole MC, Ceroni L, Caletti G. Performance of the forward-view echoendoscope for pancreaticobiliary examination in patients with status post-upper gastrointestinal surgery. Endosc Ultrasound 2015;4:336-341.
    Pubmed KoreaMed CrossRef
  7. Krishnamoorthi R, Jayaraj M, Thoguluva Chandrasekar V, et al. EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis. Surg Endosc 2020;34:1904-1913.
    Pubmed CrossRef
  8. Mohan BP, Khan SR, Trakroo S, et al. Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis. Endoscopy 2020;52:96-106.
    Pubmed CrossRef
  9. Lisotti A, Bacchilega I, Linguerri R, Fusaroli P. Endoscopic ultrasound-guided gallbladder drainage as a strategy to overcome shortage of operating rooms and intensive care unit beds during Covid-19 crisis. Endoscopy 2020;52:E263-E264.
    Pubmed KoreaMed CrossRef
  10. Lisotti A, Fusaroli P. EUS-guided gallbladder drainage during a pandemic crisis: how the COVID-19 outbreak could impact interventional endoscopy. Dig Liver Dis 2020;52:613-614.
    Pubmed KoreaMed CrossRef
  11. Lisotti A, Linguerri R, Bacchilega I, Cominardi A, Marocchi G, Fusaroli P. EUS-guided gallbladder drainage in high-risk surgical patients with acute cholecystitis-procedure outcomes and evaluation of mortality predictors. Surg Endosc. Epub 2021 Jan 28; https://doi.org/10.1007/s00464-021-08318-z.
    Pubmed KoreaMed CrossRef
  12. Fusaroli P, Serrani M, Sferrazza S, Linguerri R, Jovine E, Lisotti A. Elective cholecystectomy after reversal of septic shock using multimodality endoscopic gallbladder drainage. Endoscopy 2018;50:E299-E300.
    Pubmed CrossRef
  13. Lisotti A, Cominardi A, Bacchilega I, Fusaroli P. Failed endoscopic ultrasound-guided gallbladder drainage due to severe bleeding immediately rescued by redo-drainage under contrast-harmonic guidance. Endoscopy 2020;52:517-519.
    Pubmed CrossRef
  14. Fusaroli P, D'Ercole MC, De Giorgio R, Serrani M, Caletti G. Contrast harmonic endoscopic ultrasonography in the characterization of pancreatic metastases (with video). Pancreas 2014;43:584-587.
    Pubmed CrossRef
  15. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of localized gallbladder lesions. Dig Endosc 2018;30:98-106.
    Pubmed CrossRef
  16. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. J Gastroenterol Hepatol 2017;32:1686-1692.
    Pubmed CrossRef
  17. Guo J, Giovannini M, Sahai AV, et al. A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction. Endosc Ultrasound 2018;7:356-365.
    Pubmed KoreaMed CrossRef
  18. Guo J, Saftoiu A, Vilmann P, et al. A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy. Endosc Ultrasound 2017;6:285-291.
    Pubmed KoreaMed CrossRef
  19. Fusaroli P, Kypraios D, Eloubeidi MA, Caletti G. Levels of evidence in endoscopic ultrasonography: a systematic review. Dig Dis Sci 2012;57:602-609.
    Pubmed CrossRef
  20. Teoh AYB, Kitano M, Itoi T, et al. Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: an international randomised multicentre controlled superiority trial (DRAC 1). Gut 2020;69:1085-1091.
    Pubmed CrossRef
  21. Luk SW, Irani S, Krishnamoorthi R, Wong Lau JY, Wai Ng EK, Teoh AY. Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis. Endoscopy 2019;51:722-732.
    Pubmed CrossRef

Article

Letter to the Editor

Gut and Liver 2021; 15(4): 634-636

Published online July 15, 2021 https://doi.org/10.5009/gnl210074

Copyright © Gut and Liver.

Endoscopic Techniques for Gallbladder Drainage: Never without My Endoscopic Ultrasound

Gianmarco Marocchi , Andrea Lisotti , and Pietro Fusaroli

Gastrointestinal Unit, Department of Medical and Surgical Sciences, Hospital of Imola, University of Bologna, Imola, Italy

Correspondence to:Gianmarco Marocchi
ORCID https://orcid.org/0000-0001-9925-3486
E-mail gianmarco.marocchi2@gmail.com

Received: February 14, 2021; Accepted: February 22, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

To the Editor:

We read with great interest the article by Yoshida et al.1 published online in January 2021, that described cholangioscopic assistance for endoscopic transpapillary gallbladder drainage (ETGBD) in 101 high-risk surgical patients with acute cholecystitis. The authors reported that the optional use of cholangioscopy could lead to a significantly higher technical success rate than the use of conventional ETGBD alone (94.1% vs 72%). A 4-step classification was also developed to categorize the factors that could complicate ETGBD. The authors conclude that the application of cholangioscopic assistance in a coordinated manner, based on the 4-step classification, represents a valid strategy for improving the success rate of ETGBD, in particular in the early stages, when there is a greater probability of technical failure. However, as stated by the authors, ETGBD is a challenging procedure that requires advanced endoscopic techniques and carries the possibility of adverse events, such as post-ERCP pancreatitis. Furthermore, advancing the guidewire in the presence of tortuosity of the cystic duct remains an unsolved issue, even with cholangioscopic assistance.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) represents a valid alternative that can overcome the abovementioned problems. EUS-GBD is a well described procedure in high-risk surgical patients with acute cholecystitis, either as a bridge to surgery or as a definitive therapy.2-6 Two recent systematic reviews and meta-analyses reported a significantly higher clinical success rate with EUS-GBD than with ETGBD7 and percutaneous gallbladder drainage,8 with similar rates of adverse events between the procedures. In the past year, faced with issues related to the COVID-19 (coronavirus disease 2019) pandemic, such as a shortage of operating rooms and intensive care unit beds, our group suggested that EUS-GBD should be considered the intervention of choice in patients with acute cholecystitis to obtain a definitive treatment and allow rapid patient discharge.9 We reported the case of an 80-year-old woman with sepsis due to acute cholecystitis that was successfully managed outside the operating room and intensive care unit. In that patient, gallbladder drainage was achieved by the EUS-guided placement of a 10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS). The procedure lasted 20 minutes and no adverse events occurred. The patient was discharged 4 hours later.10 Furthermore, we previously reported that in most cases, EUS-GBD could be performed without general anesthesia, avoiding intensive care unit admission and reducing the occurrence of anesthesiology-related adverse events.11,12 Adverse effects of EUS-GBD, such as bleeding and perforation, have been described in a small percentage of cases.8 In our experience, a conspicuous bleeding due to the puncture of a gallbladder wall arteriole following the insertion of a LAMS was successfully rescued by the deployment of a second LAMS close to the bleeding point, leading to mechanical hemostasis.13 In that case, contrast-enhanced harmonic EUS (CH-EUS) played a central role. Although CH-EUS has already been shown to be a useful tool in the diagnostic phase,14-16 increasing exexperience with CH-EUS guided therapeutic interventions is being reported. In the aforementioned case, CH-EUS was crucial for the identification of the feeding vessel, allowing the deployment of the second LAMS in a targeted manner. Furthermore, the absence of spreading of the contrast dye demonstrated the success of the rescue strategy.

As was brilliantly demonstrated by Yoshida et al.,1 some technological developments can be adopted to simplify complex interventional procedures. In addition to the introduction of dedicated devices for EUS-guided drainage that allow the spread of pancreatic fluid collection or biliary drainage,17-19 it was found that the use of a single-operator digital cholangioscope could improve the technical and clinical outcomes of ETGBD. Finally, several drainage strategies are available for use in high-risk surgical patients with acute cholecystitis; in our opinion, EUS-GBD seems to offer some marked advantages over ETGBD and percutaneous gallbladder drainage,20,21 providing a definitive therapy with high rates of technical and clinical success while requiring less anesthesia and a shorter duration of hospitalization.

CONFLICTS OF INTEREST


No potential conflict of interest relevant to this article was reported.

References

  1. Yoshida M, Naitoh I, Hayashi K, et al. Four-step classification of endoscopic transpapillary gallbladder drainage and the practical efficacy of cholangioscopic assistance. Gut Liver 2021;15:476-485.
    Pubmed KoreaMed CrossRef
  2. Itoi T, Binmoeller KF, Shah J, et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012;75:870-876.
    Pubmed CrossRef
  3. Dollhopf M, Larghi A, Will U, et al. EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device. Gastrointest Endosc 2017;86:636-643.
    Pubmed CrossRef
  4. Fusaroli P, Jenssen C, Hocke M, et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V-EUS-Guided Therapeutic Interventions (short version). Ultraschall Med 2016;37:412-420.
    Pubmed CrossRef
  5. Mori Y, Itoi T, Baron TH, et al. Tokyo guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018;25:87-95.
    Pubmed CrossRef
  6. Fusaroli P, Serrani M, Lisotti A, D'Ercole MC, Ceroni L, Caletti G. Performance of the forward-view echoendoscope for pancreaticobiliary examination in patients with status post-upper gastrointestinal surgery. Endosc Ultrasound 2015;4:336-341.
    Pubmed KoreaMed CrossRef
  7. Krishnamoorthi R, Jayaraj M, Thoguluva Chandrasekar V, et al. EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis. Surg Endosc 2020;34:1904-1913.
    Pubmed CrossRef
  8. Mohan BP, Khan SR, Trakroo S, et al. Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis. Endoscopy 2020;52:96-106.
    Pubmed CrossRef
  9. Lisotti A, Bacchilega I, Linguerri R, Fusaroli P. Endoscopic ultrasound-guided gallbladder drainage as a strategy to overcome shortage of operating rooms and intensive care unit beds during Covid-19 crisis. Endoscopy 2020;52:E263-E264.
    Pubmed KoreaMed CrossRef
  10. Lisotti A, Fusaroli P. EUS-guided gallbladder drainage during a pandemic crisis: how the COVID-19 outbreak could impact interventional endoscopy. Dig Liver Dis 2020;52:613-614.
    Pubmed KoreaMed CrossRef
  11. Lisotti A, Linguerri R, Bacchilega I, Cominardi A, Marocchi G, Fusaroli P. EUS-guided gallbladder drainage in high-risk surgical patients with acute cholecystitis-procedure outcomes and evaluation of mortality predictors. Surg Endosc. Epub 2021 Jan 28; https://doi.org/10.1007/s00464-021-08318-z.
    Pubmed KoreaMed CrossRef
  12. Fusaroli P, Serrani M, Sferrazza S, Linguerri R, Jovine E, Lisotti A. Elective cholecystectomy after reversal of septic shock using multimodality endoscopic gallbladder drainage. Endoscopy 2018;50:E299-E300.
    Pubmed CrossRef
  13. Lisotti A, Cominardi A, Bacchilega I, Fusaroli P. Failed endoscopic ultrasound-guided gallbladder drainage due to severe bleeding immediately rescued by redo-drainage under contrast-harmonic guidance. Endoscopy 2020;52:517-519.
    Pubmed CrossRef
  14. Fusaroli P, D'Ercole MC, De Giorgio R, Serrani M, Caletti G. Contrast harmonic endoscopic ultrasonography in the characterization of pancreatic metastases (with video). Pancreas 2014;43:584-587.
    Pubmed CrossRef
  15. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of localized gallbladder lesions. Dig Endosc 2018;30:98-106.
    Pubmed CrossRef
  16. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. J Gastroenterol Hepatol 2017;32:1686-1692.
    Pubmed CrossRef
  17. Guo J, Giovannini M, Sahai AV, et al. A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction. Endosc Ultrasound 2018;7:356-365.
    Pubmed KoreaMed CrossRef
  18. Guo J, Saftoiu A, Vilmann P, et al. A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy. Endosc Ultrasound 2017;6:285-291.
    Pubmed KoreaMed CrossRef
  19. Fusaroli P, Kypraios D, Eloubeidi MA, Caletti G. Levels of evidence in endoscopic ultrasonography: a systematic review. Dig Dis Sci 2012;57:602-609.
    Pubmed CrossRef
  20. Teoh AYB, Kitano M, Itoi T, et al. Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: an international randomised multicentre controlled superiority trial (DRAC 1). Gut 2020;69:1085-1091.
    Pubmed CrossRef
  21. Luk SW, Irani S, Krishnamoorthi R, Wong Lau JY, Wai Ng EK, Teoh AY. Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis. Endoscopy 2019;51:722-732.
    Pubmed CrossRef
Gut and Liver

Vol.15 No.4
July, 2021

pISSN 1976-2283
eISSN 2005-1212

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