open access endoscopic ultrasound-guided gallbladder ...e-ce.org/upload/pdf/ce-2018-024.pdf ·...
TRANSCRIPT
450 Copyright © 2018 Korean Society of Gastrointestinal Endoscopy
REVIEWClin Endosc 2018;51:450-462https://doi.org/10.5946/ce.2018.024Print ISSN 2234-2400 • On-line ISSN 2234-2443
Endoscopic Ultrasound-Guided Gallbladder Drainage Using a Lumen-Apposing Metal Stent for Acute Cholecystitis: A Systematic Review
Deepanshu Jain1, Bharat Singh Bhandari2, Nikhil Agrawal3 and Shashideep Singhal4
1Division of Gastroenterology and Hepatology, Department of Digestive Diseases and Transplantation, Internal Medicine, Einstein Healthcare Network, Philadelphia, PA, 2Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA, 3Department of Internal Medicine, University of Buffalo, Buffalo, NY, 4Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, TX, USA
Surgery remains the standard treatment for acute cholecystitis except in high-risk candidates where percutaneous transhepatic gallblad-der drainage (PT-GBD), endoscopic transpapillary cystic duct stenting (ET-CDS), and endoscopic ultrasound-guided gallbladder drain-age (EUS-GBD) are potential choices. PT-GBD is contraindicated in patients with coagulopathy or ascites and is not preferred by pa-tients owing to aesthetic reasons. ET-CDS is successful only if the cystic duct can be visualized and cannulated. For 189 patients who underwent EUS-GBD via insertion of a lumen-apposing metal stent (LAMS), the composite technical success rate was 95.2%, which in-creased to 96.8% when LAMS was combined with co-axial self-expandable metal stent (SEMS). The composite clinical success rate was 96.7%. We observed a small risk of recurrent cholecystitis (5.1%), gastrointestinal bleeding (2.6%) and stent migration (1.1%). Cautery enhanced LAMS significantly decreases the stent deployment time compared to non-cautery enhanced LAMS. Prophylactic placement of a pigtail stent or SEMS through the LAMS avoids re-interventions, particularly in patients, where it is intended to remain in situ in-definitely. Limited evidence suggests that the efficacy of EUS-GBD via LAMS is comparable to that of PT-GBD with the former show-ing better results in postoperative pain, length of hospitalization, and need for antibiotics. EUS-GBD via LAMS is a safe and efficacious option when performed by experts. Clin Endosc 2018;51:450-462
Key Words: Acute cholecystitis; Endoscopic ultrasound; Lumen-apposing metal stent
Open Access
IntRoDUCtIon
Approximately 20 million Americans are estimated to have gallstones, and approximately 300,000 cholecystectomies are performed annually.1 Approximately 1%–2% of patients with asymptomatic gallstones become symptomatic each year. Acute
cholecystitis, which is the most common complication of gall-stones occurs in 10% of symptomatic patients.2
Surgery—open or laparoscopic (performed preferentially) is the standard treatment for acute cholecystitis.3 Cholecystecto-my rates were observed to increase rapidly initially, after which they stabilized in the late 1990s and currently may even be declining in the U.S.4 Surgery is contraindicated in a few pa-tients with advanced age and multiple comorbidities. Non-sur-gical gallbladder drainage (GBD) can be performed via a per-cutaneous transhepatic (PT) or an endoscopic route with or without an endoscopic ultrasound (EUS).
Perihepatic ascites and coagulopathy are relative contrain-dications for PT-GBD. PT-GBD causes postoperative pain in approximately 12% of patients.5 Additionally, catheter obstruc-tion, dislodgement and migration require multiple post-pro-cedural interventions and long-term care. PT-GBD can be use-
Received: January 7, 2018 Revised: February 14, 2018 Accepted: February 18, 2018Correspondence: Shashideep SinghalDivision of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 4.234, Houston, TX 77030, USAtel: +1-713-500-6677, Fax: +1-713-500-6699, E-mail: [email protected]: https://orcid.org/0000-0002-8783-4889
cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
451
Jain D et al. EUS-Guided GBD via LAMS
ful as either a bridge to surgery or occasionally is planned as destination therapy, although patients may report discomfort from external drainage tubes and reject this procedure owing to aesthetic reasons.
In the absence of EUS, endoscopic drainage of the GB has been attempted via a transpapillary approach aimed at stent-ing the cystic duct. This technique is feasible only if the cystic duct shows opacification on a cholangiogram and a guide-wire can be successfully passed into the cystic duct. Reportedly, the technical success rate (TSR) of this approach is approximately 91%.6 Common complications include bleeding, stent migra-tion or occlusion, sedation-related adverse events, and those associated with the endoscopic retrograde cholangiopancrea-tography (ERCP) procedure itself.
EUS-GBD is a relatively newer application of the EUS-guid-ed approach to create an iatrogenic fistula between the GB and the gastrointestinal (GI) tract. EUS-GBD has been performed using plastic stents, nasobiliary drainage tubes, or self-ex-pandable metal stents (SEMS); however, the high risk of stent migration and bile leakage secondary to lack of apposition of the luminal walls has been considered an obstacle to achieving safe clinical outcomes. A lumen-apposing metal stent (LAMS) is a saddle-shaped stent designed from braided nitinol wires with double-walled flanges perpendicular to the lumen on both sides to provide adequate anchorage across the non-ad-herent luminal structures. It is completely covered with silicone to counteract tissue ingrowth and tract leakage and to allow removability. In this article, we summarize the indications, technique, outcomes, and adverse events associated with EUS-GBD using LAMS based on our review of 10 original studies.
MAtERIALS AnD MEtHoDS
Two authors individually reviewed the English literature from inception through September 2017. PubMed and Google Scholar were used to identify peer-reviewed original and re-view articles using the following key words: “Lumen-apposing metal stents (LAMS)”, “gallbladder drainage”, and “endoscopic ultrasound”. Only studies involving humans were selected. The references cited for pertinent studies were manually searched to identify additional relevant studies. Our search results yield-ed 10 studies.7-16 Indications, procedural details, technical and clinical outcomes, as well as adverse events with their manage-ment were reviewed for each study.
RESULtS
Ten original studies were included in our review article.
All were retrospective studies7-15 except 1.16 Three studies en-rolled patients from multiple centers11,15,16 and the rest were single-center studies.7-10,12-14 The reported literature described studies from the US,8,10-13,15 Spain,7 Japan,9 Germany14 and the Netherlands.16 Details regarding all studies have been summa-rized in Table 1.
Patient characteristicsMost patients in our study cohort were aged ≥60 years7-16
with only a few patients aged <50 years.11,13,15 Our study showed an even distribution of women (47.1%) and men (52.9%) in a ratio of 1:1.1.7-16 The retrospective studies that compared outcomes between EUS-GBD and PT-GBD showed no statis-tically significant intergroup differences in terms of baseline population characteristics, etiology of cholecystitis, site of ob-struction, median thickness of the GB wall, median duration of cholecystitis, and antibiotic exposure prior to the planned intervention.15
IndicationsThe most common indication for the procedure was acute
cholecystitis7,9,11-16 in addition to acute cholangitis,8 GB hy-drops,10,11 or biliary obstruction.11 The underlying etiology was either an isolated condition or a combination of cholelithiasis, choledocholithiasis, acalculous cholecystitis, or malignancies such as pancreatic adenocarcinoma, cholangiocarcinoma, or GB adenocarcinoma.7-16 All such patients had been deemed poor surgical candidates and had either refused to undergo PT-GBD or preferred to undergo EUS-GBD.7-12,14-16 A study showed that all patients who underwent PT-GBD continued to remain poor surgical candidates during follow-up and re-quired management with internal drainage using EUS-GBD.13 In patients with biliary obstruction, ERCP failed to relieve ob-struction secondary to technically challenging anatomy.8 In addition to patient preference, PT-GBD was considered unsafe in a few patients with concomitant perihepatic ascites, or co-agulopathy, and in those who needed to continue the use of blood thinners, or were at a high risk of tube dislodgement (patients with dementia, and agitated behavior, among other such conditions).11
Procedural characteristics
AnesthesiaOnly 4 studies described the nature of anesthesia used for
the procedure, which varied from general,11,15 and monitored anesthesia14,16 to conscious sedation.16 These results are highly center specific. No patient-reported outcomes are available to compare procedure tolerance across different studies, al-though the TSR remained comparable independent of the
452
Tabl
e 1.
Des
cripti
ve S
umma
ry of
Each
Indiv
idual
Stud
y
Stud
y Lo
catio
nty
pe o
fst
udy
num
ber o
fPa
tient
sIn
dica
tion/
Dis
ease
Age
(yr)
an
d se
xte
chni
cal
outc
ome
Clin
ical
ou
tcom
eFo
llow
up
dura
tion
Sten
t left
/re-
trie
ved
Adv
erse
even
ts
de la
Ser
na-H
igue
ra
et a
l. (2
013)
7
Spa
in
Retro
spec
tive
Cas
e ser
ies
13In
dica
tion-
1. A
cute
c
hole
cysti
tis
(no
n-su
rgic
al
can
dida
te)
Etio
logy
- 1
. Cho
lelith
iasis
- 9
/13
2
. Cho
lelith
iasis
+ P
ancr
eatic
canc
er-
2/1
3 3
. Cho
lelith
iasis
+ C
hola
ngio
carc
inom
a- 1
/13
4. Ch
olan
gioc
arcin
oma-
1/1
3
1. M
ean
age-
7
9.9
(ra
nge,
57–9
7)2.
Gen
der
dist
ribut
ion-
a) F
- 5 b
) M- 8
1. S
ucce
ss-
11/
13
(84
.6%
) 2.
Fai
lure
of
ins
ertio
n- 2
/13
a) 1
/2- T
ight
c
obbl
esto
ne G
B b
) 1/2
- U
ncon
trolle
d s
tent
rele
ase-
c
ompl
ete
dep
loym
ent
int
o th
e gas
tric
l
umen
-
Succ
ess-
11/
11
(10
0%)
Para
met
er-
1. I
mm
edia
te
sym
ptom
relie
f2.
Nor
mal
izat
ion
of L
FTs a
nd
acu
te p
hase
r
eact
ants
1. M
ean-
100
.81
days
(ra
nge,
24–
210
)
1. S
tent
left
in
situ
- 10/
112.
Ste
nt re
trie
ved-
1
/11
(no
rep
lace
men
t s
tent
pla
ced
due
to sy
mpt
om
res
olut
ion
and
col
lapse
of G
B w
all)
Com
posit
e pro
cedu
re r
elate
d A
E- 2
1.
Sca
nt h
emat
oche
zia
with
out a
nem
ia- 1
/2
(re
solv
ed w
ith
con
serv
ativ
e Mx)
2. M
ild ri
ght u
pper
q
uadr
ant p
ain-
1/2
(
reso
lved
with
c
onse
rvat
ive M
x)
Itoi e
t al.
(20
13)8
USA
Cas
e Rep
ort
1In
dica
tion-
1
. Acu
te ch
olan
gitis
(
ERCP
tech
nica
lly
cha
lleng
ing)
Etio
logy
- 1
. Pan
crea
tic h
ead
mas
s with
c
onco
mita
nt
duo
dena
l and
b
iliar
y ob
struc
tion
1. A
ge- 5
72.
Gen
der
dist
ribut
ion-
a) F
- 0 b
) M- 1
Succ
ess-
1/1
(
100%
)Su
cces
s- 1
/1 (
100%
)Pa
ram
eter
- 1
. Clin
ical
s
ympt
oms
2. L
FTs
nor
mal
ized
1 yr
1. S
tent
left
in si
tu-
1/1
Non
e
Itoi e
t al.
(20
14)9
Jap
an
Cas
e rep
ort
1In
dica
tion-
1. A
cute
chol
ecys
titis
(N
on-s
urgi
cal
can
dida
te)
1. A
ge- 9
62.
Gen
der
dist
ribut
ion-
a) F
- 1 b
) M- 0
Succ
ess-
1/1
(
100%
)Su
cces
s- 1
/1
(10
0%)
N/A
1. S
tent
retr
ieve
d-
1/1
(2 w
eeks
pos
t p
lace
men
t alo
ng
with
20 ×
30 m
m
gal
lston
e r
emov
al w
ith
help
of
lith
otrip
ter)
Non
e
Thar
ian
et a
l. (2
016)
10
USA
Cas
e rep
ort
1In
dica
tion-
1
. Dist
ende
d G
BD
iseas
e-
1. A
deno
carc
inom
a o
f GB
neck
1. A
ge- 8
12.
Gen
der
dist
ribut
ion-
a) F
- 0 b
) M- 1
Succ
ess-
1/1
(
100%
)Su
cces
s- 1
/1
(10
0%)
Para
met
er-
1. C
linic
al
sym
ptom
s
1 m
o1.
Ste
nt in
situ
- 1
/1N
one
453
Jain D et al. EUS-Guided GBD via LAMS
Tabl
e 1.
Con
tinue
d
Stud
y Lo
catio
nty
pe o
fst
udy
num
ber o
fPa
tient
sIn
dica
tion/
Dis
ease
Age
(yr)
an
d se
xte
chni
cal
outc
ome
Clin
ical
ou
tcom
eFo
llow
up
dura
tion
Sten
t left
/re-
trie
ved
Adv
erse
even
ts
Iran
i e
t al.
(201
5)11
USA
Mul
ticen
ter
Ret
rosp
ectiv
e15
Indi
catio
n-
1. A
cute
calc
ulou
s c
hole
cysti
tis- 7
/15
2. N
on ca
lcul
ous
cho
lecy
stitis
- 4/1
5 3
. Bili
ary
obstr
uctio
n- 2
/15
4. G
allb
ladd
er
hyd
rops
- 1/1
5 5
. Sym
ptom
atic
c
holel
ithia
sis- 1
/15
(A
ll w
ere n
on-
sur
gica
l can
dida
tes
and
all r
efus
ed
per
cuta
neou
s d
rain
age)
1. M
edia
n a
ge- 7
4 (
rang
e, 42
–89)
2. G
ende
r d
istrib
utio
n-
a) F
- 7 b
) M- 8
1. S
ucce
ss-
14/
15 (9
3%)
2. S
ucce
ss w
ith a
ssist
ance
- 1/1
5 (
salv
aged
by
pla
cing
SEM
S v
ia L
AM
S)
Succ
ess-
1
5/15
(100
%)
Mea
n- 1
60 (
rang
e, 3
9– 2
60)
day
sM
odal
ity-
Pho
ne ca
lls,
Clin
ic v
isits,
I
mag
ing
stu
dies
1. S
tent
in si
tu-
15/
15
Com
posit
e pro
cedu
re
rela
ted
AE-
11.
Pos
t-pro
cedu
re fe
ver-
1
/15
(suc
cess
fully
trea
ted
with
antib
iotic
s)
Kum
ta
et a
l. (2
016)
12
USA
Cas
e rep
ort
1In
dica
tion-
chro
nic
calc
ulou
s c
hole
cysti
tis
(no
t a su
rgic
al
can
dida
te an
d re
fuse
d p
ercu
tane
ous
dra
inag
e)
1. A
ge- 7
7 ye
ars
2. G
ende
r d
istrib
utio
n- a
) F- 1
Succ
ess-
1/1
(
100%
)Su
cces
s-
1/1
(100
%)
Para
met
er-
1. C
linic
al
sym
ptom
s
6 m
o1.
Ste
nt le
ft in
situ
- 1
/1N
one
Law
e
t al.
(201
6)13
USA
Retro
spec
tive
Sing
le ce
nter
Cas
e ser
ies
7In
dica
tion-
acut
e c
alcul
ous c
holec
ystit
is (
prio
r per
cuta
neou
s d
rain
and
poor
s
urgi
cal c
andi
date
s)
1. M
edia
n A
ge- 5
7 (
rang
e, 32
– 81
)2.
Gen
der
dist
ribut
ion-
a) F
-1 b
) M -
6
Succ
ess-
5
/7 (7
1.4%
)Su
cces
s with
a
ssist
ance
- 2/7
(
salv
aged
with
S
EMS
pla
cem
ent
thr
ough
LA
MS)
Succ
ess-
7
/7 (1
00 %
)Pa
ram
eter
- 1
. Clin
ical
s
ympt
oms
4 m
o (
Inte
rqua
rtile
ran
ge, 3
.5–
5.5
)
1. S
tent
left
in si
tu-
4/7
2.
Ste
nt re
trie
ved-
3/7
a
) 2/3
- rep
lace
d w
ith d
oubl
e p
igta
il ste
nt at
6
wee
ks an
d 4
mo
b) 1
/3- r
emov
ed
to
allo
w st
one
ext
ract
ion
whi
ch
spo
ntan
eous
ly
pas
sed
into
i
leos
tom
y ba
g
Non
e
454
Tabl
e 1.
Con
tinue
d
Stud
y Lo
catio
nty
pe o
fst
udy
num
ber o
fPa
tient
sIn
dica
tion/
Dis
ease
Age
(yr)
an
d se
xte
chni
cal
outc
ome
Clin
ical
ou
tcom
eFo
llow
up
dura
tion
Sten
t left
/re-
trie
ved
Adv
erse
even
ts
Dol
lhop
f e
t al.
(201
7)14
Ger
man
y
Retro
spec
tive
Sing
le ce
nter
75In
dica
tion
- acu
te
calc
ulou
s a
nd ac
alcu
lous
c
hole
cysti
tis
(po
or su
rgic
al
can
dida
tes)
1. M
edia
n a
ge- 7
5±11
(
rang
e, 41
–96)
2.
Gen
der
dist
ribut
ion-
a) F
- 39
b) M
- 36
1. S
ucce
ss-
74/
75 (9
8.7%
)2.
Fai
lure
- 1/7
5 (
equi
pmen
t m
alfun
ctio
ning
- l
eadi
ng to
g
astr
ic
per
fora
tion
man
aged
s
urgi
cally
)
Succ
ess-
7
1/74
(95.
9%)
Para
met
er-
1. C
linic
al
sym
ptom
s Fa
ilure
- 3/7
4 (
deat
h on
pos
t p
roce
dure
d
ay 3
, 13
and
27
seco
ndar
y t
o w
orse
ning
s
epsis
)
1. M
ean:
2
01±2
26 (
rang
e, 2
–1,1
92)
day
s
1. S
tent
left
in si
tu-
69/
752.
Ste
nt re
trie
ved-
5
/75
3. S
tent
m
igra
tion-
1/7
5 (
spon
tane
ous,
per
siste
nt
cho
lecy
sto-
gas
tric
fistu
la
with
no
clini
cal
con
sequ
ence
s)
Com
posit
e pro
cedu
re r
elate
d A
E- 1
01.
Maj
or b
leed
ing-
1/1
0 (
reso
lved
with
c
onse
rvat
ive
man
agem
ent)
2. R
ecur
rent
chol
ecys
titis-
3
/10
a) 1
/3- c
onse
rvat
ive
man
agem
ent
b) 2
/3- d
oubl
e pig
tail
ste
nt p
lace
d vi
a LA
MS
3. M
igra
tion-
2/1
0 a
) 1/2
- pro
xim
al
mig
ratio
n in
to G
B a
t 8 m
pos
t pro
cedu
re
(en
dosc
opic
rem
oval
and
rep
lace
men
t with
a
noth
er L
AM
S) b
) 1/2
- int
raga
stric
m
igra
tion
at d
ay 5
pos
t p
roce
dure
(end
osco
pic
ste
nt re
trie
val a
nd
clo
sure
of fi
stula
with
c
lip)
4. B
ouve
ret s
yndr
ome-
1
/10-
4 m
pos
t pro
cedu
re
(en
dosc
opy
and
lith
otrip
sy o
f occ
ludi
ng
sto
ne5.
Sep
sis-
3/1
0- le
adin
g to
dea
th
455
Jain D et al. EUS-Guided GBD via LAMS
Tabl
e 1.
Con
tinue
d
Stud
y Lo
catio
nty
pe o
fst
udy
num
ber o
fPa
tient
sIn
dica
tion/
Dis
ease
Age
(yr)
an
d se
xte
chni
cal
outc
ome
Clin
ical
ou
tcom
eFo
llow
up
dura
tion
Sten
t left
/re-
trie
ved
Adv
erse
even
ts
Dol
lhop
f e
t al.
(201
7)14
Ger
man
y
Retro
spec
tive
Sing
le ce
nter
75In
dica
tion
- acu
te
calc
ulou
s a
nd ac
alcu
lous
c
hole
cysti
tis
(po
or su
rgic
al
can
dida
tes)
1. M
edia
n a
ge- 7
5±11
(
rang
e, 41
–96)
2.
Gen
der
dist
ribut
ion-
a) F
- 39
b) M
- 36
1. S
ucce
ss-
74/
75 (9
8.7%
)2.
Fai
lure
- 1/7
5 (
equi
pmen
t m
alfun
ctio
ning
- l
eadi
ng to
g
astr
ic
per
fora
tion
man
aged
s
urgi
cally
)
Succ
ess-
7
1/74
(95.
9%)
Para
met
er-
1. C
linic
al
sym
ptom
s Fa
ilure
- 3/7
4 (
deat
h on
pos
t p
roce
dure
d
ay 3
, 13
and
27
seco
ndar
y t
o w
orse
ning
s
epsis
)
1. M
ean:
2
01±2
26 (
rang
e, 2
–1,1
92)
day
s
1. S
tent
left
in si
tu-
69/
752.
Ste
nt re
trie
ved-
5
/75
3. S
tent
m
igra
tion-
1/7
5 (
spon
tane
ous,
per
siste
nt
cho
lecy
sto-
gas
tric
fistu
la
with
no
clini
cal
con
sequ
ence
s)
Com
posit
e pro
cedu
re r
elate
d A
E- 1
01.
Maj
or b
leed
ing-
1/1
0 (
reso
lved
with
c
onse
rvat
ive
man
agem
ent)
2. R
ecur
rent
chol
ecys
titis-
3
/10
a) 1
/3- c
onse
rvat
ive
man
agem
ent
b) 2
/3- d
oubl
e pig
tail
ste
nt p
lace
d vi
a LA
MS
3. M
igra
tion-
2/1
0 a
) 1/2
- pro
xim
al
mig
ratio
n in
to G
B a
t 8 m
pos
t pro
cedu
re
(en
dosc
opic
rem
oval
and
rep
lace
men
t with
a
noth
er L
AM
S) b
) 1/2
- int
raga
stric
m
igra
tion
at d
ay 5
pos
t p
roce
dure
(end
osco
pic
ste
nt re
trie
val a
nd
clo
sure
of fi
stula
with
c
lip)
4. B
ouve
ret s
yndr
ome-
1
/10-
4 m
pos
t pro
cedu
re
(en
dosc
opy
and
lith
otrip
sy o
f occ
ludi
ng
sto
ne5.
Sep
sis-
3/1
0- le
adin
g to
dea
th
Tabl
e 1.
Con
tinue
d
Stud
y Lo
catio
nty
pe o
fst
udy
num
ber o
fPa
tient
sIn
dica
tion/
Dis
ease
Age
(yr)
an
d se
xte
chni
cal
outc
ome
Clin
ical
ou
tcom
eFo
llow
up
dura
tion
Sten
t left
/re-
trie
ved
Adv
erse
even
ts
Iran
i e
t al.
(201
7)15
USA
, Eur
ope,
Asia
Retro
spec
tive
Mul
ticen
ter
EUS
guid
ed
GB
dra
inag
e (
EUS-
GBD
)- 4
5
Indi
catio
n -
1) A
cute
calc
ulou
s a
nd ac
alcu
lous
c
hole
cysti
tis (p
oor
sur
gica
l can
dida
tes)
1. M
edia
n a
ge- 5
5 (
rang
e, 25
–87)
2. G
ende
r d
istrib
utio
n- a
) F- 1
6 b
) M- 2
9
1. S
ucce
ss-
44/
45 (9
8%)
2. S
ucce
ss w
ith
ass
istan
ce- 1
/45
(sa
lvag
ed w
ith
10 ×
60 m
m
ful
ly co
vere
d b
iliar
y m
etal
s
tent
pla
ced
via
LA
MS)
1. S
ucce
ss-
43/
45 (9
6%)
2. M
edia
n pa
in
sco
re o
n po
st p
roce
dure
Day
1
- 2.5
(
rang
e, 1–
9)3.
Med
ian
hos
pita
l sta
y p
ost
int
erve
ntio
n- 3
(ra
nge,
1–23
)4.
Num
ber o
f r
e-in
terve
ntio
ns-
11
215
(ran
ge,
1–6
21) d
ays
1. S
tent
left
in si
tu-
44/
44C
ompo
site p
roce
dure
r
elate
d A
E- 8
1. B
leed
ing-
2/8
a) 1
/2- 3
day
s pos
t p
roce
dure
(tre
ated
by
clo
t eva
cuat
ion
and
pig
tail
stent
pla
cem
ent
thr
ough
LA
MS)
b)
1/2
- 6 m
o po
st p
roce
dure
(sto
pped
s
pont
aneo
usly
with
r
ever
sal o
f coa
gulo
path
y)
2. R
ecur
rent
chol
ecys
titis-
3
/8 (6
, 8 an
d 12
mo
post
pro
cedu
re)
a) 1
/3- t
reat
ed w
ith
ant
ibio
tics
b) 2
/3- e
ndos
copi
c p
lace
men
t of p
igta
il ste
nt
via
LA
MS
3. B
ile le
ak w
ith
per
itoni
tis- 1
/8- D
ay 3
p
ost p
roce
dure
(req
uire
d p
ercu
tane
ous d
rain
) 4.
Abd
omin
al p
ain-
1/8
- d
ue to
food
occ
ludi
ng
tra
ns-g
astr
ic L
AM
S (
evac
uatio
n of
food
, b
allo
on d
ilatio
n of
g
ranu
latio
n ov
ergr
owth
a
nd p
igta
il ste
nt
pla
cem
ent v
ia L
AM
S)5.
Sep
sis- 1
/8- p
erfo
rate
d G
B le
adin
g to
dea
th
456
Tabl
e 1.
Con
tinue
dSt
udy
Loca
tion
type
of
stud
yn
umbe
r of
Patie
nts
Indi
catio
n/D
isea
seA
ge (y
r)
and
sex
tech
nica
l ou
tcom
eC
linic
al
outc
ome
Follo
w u
p du
ratio
nSt
ent l
eft/r
e-tr
ieve
dA
dver
se ev
ents
Iran
i e
t al.
(201
7)15
USA
, Eur
ope,
Asia
Perc
utan
eous
tra
nshe
patic
d
rain
age
of G
B (
PT-G
BD)-
45
1. M
edia
n a
ge- 7
5 (
34–9
4)
2.G
ende
r d
istrib
utio
n- a
) F- 1
8 b
) M- 2
7
Succ
ess-
4
5/45
(100
%)
(p=
0.98
)
1. S
ucce
ss- 4
1/45
(91
%) (
p=0.
12)
2. M
edia
n pa
in
sco
re o
n po
st p
roce
dure
Day
1
- 6.5
(ran
ge,
2–1
0) (p
=0.0
01)
3. M
edia
n h
ospi
tal s
tay
pos
t i
nter
vent
ion-
9 (r
ange
, 1–1
21)
(p=
0.01
)4.
Num
ber o
f r
e-in
terv
entio
ns-
112
(p=0
.001
)
265
(ran
ge,
1–1
,638
) d
ays
Not
appl
icab
leC
ompo
site p
roce
dure
rela
ted
AE-
14
1. R
ecur
rent
chol
ecys
titis-
4
/14
(Trt
with
Abx
and
dra
in ex
chan
ge)
a) 1
/4- d
rain
d
islod
gem
ent o
n po
st p
roce
dure
day
8 b
) 3/4
- dra
in o
cclu
sion
on
post
proc
edur
e 2, 4
a
nd 6
mo
2. A
bdom
inal
pai
n w
ithou
t cho
lecy
stitis
- 3
/14
(dra
in o
cclu
sion
Trt
with
exch
ange
)3.
Cell
uliti
s- 1
/14
(Trt
with
o
ral A
bx)
4. B
ile le
ak- 3
/14
a) 1
/3- l
ead
to se
psis
and
dea
th b
) 2/3
- add
ition
al d
rain
pla
cem
ent
5. S
epsis
- 2/1
4 (le
ad to
d
eath
)6.
Jeju
nal fi
stula
- 1/1
4 (
allo
wed
trac
k to
mat
ure
fol
low
ed b
y EU
S-G
BD)
Wal
ter
et a
l. (2
016)
16
Net
herla
nds
Pros
pect
ive
Mul
ticen
ter
30In
dica
tion-
Acu
te
calc
ulou
s a
nd ac
alcu
lous
c
hole
cysti
tis (
poor
surg
ical
c
andi
date
s)
1. M
edia
n a
ge- 8
5 (
rang
e, 68
–97)
2. G
ende
r d
istrib
utio
n a
) F- 1
9 b
) M- 1
1
27/3
0 (9
0%)
26/2
7 (9
6%)
1. 2
98±8
2 da
ys fo
r al
l pat
ient
s 2.
364
±82
days
for
patie
nts
aliv
e at t
he
end
of st
udy
1. S
tent
left
in si
tu-
15/
302.
Ste
nt re
trie
ved-
1
5/30
Com
posit
e pro
cedu
re r
elate
d A
E- 6
1. R
ecur
rent
c
hole
cysti
tis- 2
/6 (d
ue to
L
AM
S ob
struc
tion
req
uirin
g its
rem
oval
)2.
Asp
iratio
n pn
eum
onia
- 1
/6 (l
eadi
ng to
dea
th)
3. P
ancr
eatic
infe
ctio
n-
1/6
(lea
ding
to d
eath
)4.
Mele
na/ t
hrom
bus i
n G
B- 1
/6 (r
esol
ved
with
c
onse
rvati
ve m
anag
emen
t) 5.
Jaun
dice
(hem
obili
a)-
1/6
(res
olve
d w
ith
con
serv
ative
man
agem
ent)
GB,
gall
blad
der;
LFT,
live
r fun
ctio
n te
sts; A
E, ad
vers
e eve
nts;
Mx,
man
agem
ent;
ERCP
, end
osco
pic r
etro
grad
e cho
langi
opan
crea
togr
aphy
; N/A
, not
avai
lable;
SEM
S, se
lf-ex
pand
able
met
al st
ent;
LAM
S, lu
men
-app
osin
g m
etal
sten
t; EU
S-G
BD, e
ndos
copi
c ultr
asou
nd-g
uide
d ga
llblad
der d
rain
age;
PT-G
BD, p
ercu
tane
ous t
rans
hepa
tic ga
llblad
der d
rain
age;
Trt,
treat
men
t; Ab
x, an
tibio
tics.
457
Jain D et al. EUS-Guided GBD via LAMS
type of anesthesia used.
Stent specificsThe LAMS is designed to allow apposition of the luminal
walls of 2 non-adherent organs. The endoscopist determines the size and length of the LAMS to be used after considering the patient-specific anatomy, GB wall thickness, and diameter of in situ GB stones (to allow unobstructed passage of the stent). Details regarding stents used by different studies have been summarized in Table 2. Because of increasing experience with the use of LAMS, a few authors recommend prophylac-tic placement of a SEMS or a plastic pigtail stent through the LAMS to prevent future occlusion and displacement.7,11,13,15 This practice is more useful in patients in whom the LAMS is intended to remain in situ indefinitely, to avoid the need for re-intervention. In addition to the above-mentioned studies, 2 authors used SEMS to provide additional length when the proximal flange of the LAMS was noted to deploy into the ex-traluminal space11,13,15 potentially salvaging a technical failure.
In our review, approximately 50% of the operations (48.2%) were performed using cautery enhanced LAMS12,14,15 and the rest were performed using non-cautery enhanced LAMS (51.8%).7-11,13,15,16
Site of punctureMost studies did not explain their choice of a transgastric vs.
a transduodenal or transjejunal approach. This decision is left to the discretion of the endoscopist after assessing the patient’s anatomy to determine the site of maximal direct apposition between the GB wall and the GI tract to allow LAMS place-ment. LAMS placement in porcine models is known to cause mature fistula tract formation within 4–5 weeks.17 The LAMS tends to cause significant tissue overgrowth, which serves as a drawback during stent removal. Walter et al. proposed that the retroperitoneal location of the duodenum allows stable tract formation compared to the stomach where peristaltic movements lead to a higher degree of tissue reaction conse-quently leading to tissue overgrowth.16
In our review comprising 189 patients, 75 (39.7%) underwent transgastric,7-9,11,14-16 113 (59.8%) underwent transduodenal,7,10-16 and 1 (0.5%) patient underwent transjejunal puncture14 to ac-cess the GB.
TechniqueAll authors used an oblique/forward viewing therapeutic lin-
ear array echoendoscope to visualize the GB. A standard 19-gauge needle was used to puncture the gastric antrum or the duodenal bulb to access the GB wall, and entry into the GB was confirmed using real-time ultrasound and color Doppler imag-ing. Next, the contrast agent was injected to obtain fluoroscopic
images of the biliary tree. A standard biliary guide-wire was coiled into the GB lumen. The tract was then dilated over the guide-wire using a balloon dilator or cystotome. A preloaded stent was then advanced over the guide-wire. The distal flange of the stent was first deployed into the GB and abutted against the wall under ultrasonographic or fluoroscopic guidance. Next, the proximal flange of the stent was deployed into the duode-num or the stomach under direct visualization, thereby perform-ing cholecystoenterostomy or cholecystogastrostomy, respec-tively. The stent position was confirmed endoscopically or fluoroscopically and via aspiration of biliary contents. If a cau-tery enhanced LAMS is being used, the puncture site, dilation of the tract and stent deployment can all be performed simulta-neously, thereby potentially decreasing the procedure time.
Procedure timeOnly 4 studies reported procedure times,11,14-16 which varied
widely between a minimum of 8 min14 and a maximum of 110 min.16 The mean procedure time varied from 22–38 min.11,14,15 The mean EUS-GBD procedure time was 6 min longer than that of a PT-GBD (p=0.02).15 Dollhopf et al. reported a signifi-cantly (p=0.04) shorter stent deployment time with the use of cautery enhanced LAMS (3.1 min) vs. non-cautery enhanced LAMS (7.7 min).14
technical outcomeThe TSR was determined by calculating the percentage of
patients who underwent successful LAMS deployment across the GB wall with drainage into the stomach or the small bow-el. The composite TSR (without SEMS) for EUS-GBD was 95.2% (180/189).7-16 The LAMS could not initially be deployed in 3 patients; however, a SEMS was successfully placed through the LAMS to bridge the gap across the GB wall to overcome this difficulty.11,13,15 The composite TSR (with SEMS) for EUS-GBD was 96.8% (183/189).7-16 The individual TSR (without SEMS) varied between 71.4%13 and 100%.8-10,12 The individual TSR (with SEMS) varied between 84.6%7 and 100%.8-13,15 Rea-sons for failure (n=6) could be attributed to a stiff cobblestone GB (1/6),7 uncontrolled stent release (1/6),7 equipment mal-function leading to gastric perforation (1/6),14 and unknown etiology (3/6).16 A study performed by Irani et al. showed that the TSR was comparable between EUS-GBD and PT-GBD (p=0.98).15
Clinical outcomesThe clinical success rate (CSR) was measured by calculating
the percentage of patients who showed significant improve-ment in clinical, laboratory, or radiological parameters post EUS-GBD via LAMS (with or without SEMS). The composite CSR was 96.7% (177/183).7-16 The individual CSR varied be-
458
Tabl
e 2.
Tech
nical
Detai
ls of
Proc
edur
e acro
ss E
ach S
tudy
Stud
y Lo
catio
n ty
pe o
f st
udy
num
ber o
fPa
tient
sSi
te o
f app
roac
h (g
astr
ic o
r duo
denu
m)
nee
dle s
ize
Sten
t spe
cific
sA
cces
sory
equi
pmen
tA
nest
hesia
Proc
edur
e du
ratio
n
de la
Ser
na-H
igue
ra
et a
l. (2
013)
7
Spa
in
Retro
spec
tive
Cas
e ser
ies
131.
Tra
nsga
stric
- 12/
13
2. T
rans
duod
enal
- 1/1
3 19
GA
. LA
MS-
1.
10×
10 m
m- 7
/11
2. 1
5×10
mm
- 4/1
13.
Fla
nge d
iam
eter
- 2
0 m
m (1
1/11
) B.
Coa
xial
SEM
S w
ithin
L
AM
S- 4
/11
1. L
inea
r ech
oend
osco
pe2.
0.0
35 in
ch g
uide
wire
3. 8
.5 F
Cys
toto
me
4. 4
mm
bili
ary
ballo
on
dila
tor
5. 1
0 m
m b
allo
on d
ilato
r
N/A
N/A
Itoi
et a
l. (2
013)
8
USA
Cas
e Rep
ort
1Tr
ansg
astr
ic- 1
/119
GA
. LA
MS
1. 1
0×10
mm
- 1/1
2.
Fla
nge d
iam
eter
- 2
0 m
m (1
/1)
1. L
inea
r ech
oend
osco
pe2.
4 m
m b
allo
on d
ilato
rN
/AN
/A
Itoi
et a
l. (2
014)
9
Jap
an
Cas
e rep
ort
1Tr
ansg
astr
ic- 1
/1N
/AA
. LA
MS
1. D
iam
eter
- 15
mm
N
/AN
/AN
/A
Thar
ian
et a
l. (2
016)
10
USA
Cas
e rep
ort
1Tr
ansd
uode
nal-
1/1
19 G
N/A
1. L
inea
r ech
oend
osco
pe2.
0.0
25 in
ch g
uide
wire
3. 4
mm
bal
loon
dila
tor
N/A
N/A
Iran
i e
t al.
(201
5)11
USA
Mul
ticen
ter
Retro
spec
tive
15Tr
ansd
uode
nal-
14/1
5Tr
ansg
astr
ic- 1
/15
19 G
A. L
AM
S1.
10×
10 m
m- 1
2/15
2.
15×
10 m
m- 3
/15
3. F
lang
e Dia
met
er-
a) 2
1 m
m- 1
2/15
b) 2
4 m
m- 3
/15
B. S
tent
thro
ugh
LAM
S 1.
7 F
× 4
cm d
oubl
e pig
t
ail s
tent
- 6/1
5 (
prop
hyla
ctic
) 2.
10×
6 cm
fully
cove
red
bili
ary
met
al st
ent-
1/15
1. L
inea
r ech
oend
osco
pe2.
0.0
25 in
ch
visi
glid
ewire
or 0
.035
i
nch
jagw
ire3.
4 m
m b
allo
on d
ilato
r o
r 6 F
/7 F
tape
red
dila
tor
4. O
ver t
he w
ire n
eedl
e k
nife
or 1
0 F
cysto
tom
e
Gen
eral
a
nesth
esia
1. M
edia
n- 3
8 (
rang
e, 15
–52)
m
in
Kum
ta
et a
l. (2
016)
12
USA
Cas
e rep
ort
1Tr
ansd
uode
nal-
1/1
N/A
A. L
AM
S w
ith ca
uter
y1.
15×
10 m
m
1. L
inea
r ech
oend
osco
pe2.
Gui
dew
ire3.
Bal
loon
dila
tor
N/A
N/A
459
Jain D et al. EUS-Guided GBD via LAMS
Tabl
e 2.
Con
tinue
d
Stud
y Lo
catio
n ty
pe o
f st
udy
num
ber o
fPa
tient
sSi
te o
f app
roac
h (g
astr
ic o
r duo
denu
m)
nee
dle s
ize
Sten
t spe
cific
sA
cces
sory
equi
pmen
tA
nest
hesia
Proc
edur
e du
ratio
n
Law
e
t al.
(201
6)13
USA
Retro
spec
tive
Sing
le ce
nter
Cas
e ser
ies
7Tr
ansd
uode
nal-
719
GA
. LA
MS
(dia
met
er/
len
gth)
1. 1
0 ×10
mm
- 5/7
2.
15 ×
10 m
m- 2
/7
B. S
tent
thro
ugh
LA
MS-
5/7
1. D
oubl
e pig
tail
stent
(
7 F
× 4
cm)-
3/7
2. B
iliar
y SE
MS
(10×6
cm) +
dou
ble p
ig
tai
l ste
nt (7
F ×
4 cm
)- 1
/7
3. B
iliar
y SE
MS
(10
mm
× 6
cm) +
bilia
ry
SEM
S (1
0 m
m ×
4 cm
)- 1
/7
1. L
inea
r ech
oend
osco
pe2.
450
cm- b
iliar
y g
uide
wire
3. C
ysto
stom
e (10
Fr)
or
bal
loon
dila
tor
N/A
N/A
Dol
lhop
f e
t al.
(201
7)14
Ger
man
y
Retro
spec
tive
Sing
le ce
nter
75Tr
ansd
uode
nal-
38
Tran
sgas
tric
- 36
Tran
sjeju
nal-
1
1. 1
9 G
- 32/
75
(42
.7%
)2.
No
need
le u
se- 4
3/75
(
LAM
S ca
uter
y)
A. L
AM
S (d
iam
eter
/ l
engt
h) w
ith ca
uter
y1.
10 ×
10 m
m- 6
5/75
2.
15 ×
10 m
m-
7/75
3. 8×8
mm
- 2/7
54.
6×8
mm
- 1/7
5
1. L
inea
r ech
oend
osco
pe2.
0.0
35 in
ch g
uide
wire
1. A
nesth
esia
m
onito
red
Mea
n- 2
6 (
rang
e, 8–
60)
min
Iran
i e
t al.
(201
7)15
USA
, Eur
ope,
Asia
Retro
spec
tive
Mul
ticen
ter
EUS-
GBD
- 4
51.
Tra
nsdu
oden
al- 3
2/45
2.
Tra
nsga
stric
- 13/
4519
GA
. LA
MS
1. 1
0 ×10
mm
- 37/
45
2. 1
5 ×10
mm
- 8/4
53.
Fla
nge d
iam
eter
- 2
1 or
24
mm
4.
Sad
dle l
engt
h-
10
mm
(45/
45)
B. S
tent
thro
ugh
LAM
S-1.
Pla
stic p
igta
il ste
nt-
24/
45
1. L
inea
r ech
oend
osco
pe2.
0.0
35 in
ch Ja
gwire
or
0.0
25 in
ch v
isigl
ide
wire
3. 4
mm
bili
ary
ballo
on
dila
tor
4. 1
0 F
cysto
stom
e or
nee
dle k
nife
or b
lank
Gen
eral
a
nesth
esia
- 4
0/45
Mea
n- 2
8 (
rang
e, 18
–52)
m
in
PT-G
BD-
45
Perc
utan
eous
tran
shep
atic
N/A
8 or
10
F se
lf lo
ckin
g p
igta
il ca
thet
erN
/AG
ener
al
ane
sthes
ia-
5/4
5 (p
<0.0
001)
Mea
n- 2
2 (
rang
e, 12
–30)
m
in (p
=0.0
2)
460
tween 95.9%14 and 100%.7-13 Among the 6 patients who showed a lack of response, GB wall perforation was considered the possible etiology in 2,14,15 and no obvious reason could be detected in the remaining 4 patients other than coexistent co-morbidities.14-16 The CSR of EUS-GBD (96%) was higher than that of PT-GBD (91%), although this result was not statistical-ly significant (p=0.12).15 Notably, the authors demonstrated a statistically significant decrease in the postoperative pain on day 1 (p=0.001), a shorter median length of hospitalization post-intervention (p=0.01), as well as fewer re-interventions (p=0.001) with EUS-GBD than with PT-GBD.15
Adverse events
SepsisLack of resolution of acute cholecystitis despite stent place-
ment resulted in progression to sepsis, necrosis of the GB wall, perforation, and death.14,15,16 These complications have been presented in detail under Clinical Outcomes.
Recurrent cholecystitisAmong the 177 patients who showed initial clinical resolu-
tion of symptoms, 9 (5.1%) presented with a repeat attack of acute cholecystitis. This condition usually occurs secondary to either stent dislodgement (usually in the early post-procedural period before the fistula matures into a tract), or occlusion (an early or late post-procedural complication) secondary to gall-stones, food bolus, clots, or tissue overgrowth over time. Pa-tients may improve with conservative management (antibiot-ics) alone14,15 or may require endoscopic debridement with placement of a pigtail stent through the LAMS or complete re-moval of the LAMS. A few authors recommend prophylactic placement of pigtail stents through the LAMS at the time of initial procedure to prevent this complication.7,11,13,15 A few au-thors also recommend performing endoscopic lavage with/without stone extraction via the LAMS after placement to prevent future attacks.7
BleedingIntraprocedural bleeding is an expected outcome because
the procedure involves the creation of a transmural fistula be-tween the GI tract and the GB wall. Bleeding was easily con-trolled in most patients and was not reported as a complication. Among 189 patients, 5 (2.6%) reported post-procedural GI bleeding,7-16 which in 4/5 patients were managed with conser-vative treatment alone (reversal of coagulopathy, administra-tion of intravenous fluids, and other such interventions).7,14-16 In 1 patient, endoscopic evaluation revealed a clot without ac-tive bleeding, which was treated with clot evacuation and placement of a pigtail stent through the LAMS.15 One patient Ta
ble
2. C
ontin
ued
Stud
y Lo
catio
n ty
pe o
f st
udy
num
ber o
fPa
tient
sSi
te o
f app
roac
h (g
astr
ic o
r duo
denu
m)
nee
dle s
ize
Sten
t spe
cific
sA
cces
sory
equi
pmen
tA
nest
hesia
Proc
edur
e du
ratio
n
Wal
ter
et a
l. (2
016)
16
Net
herla
nds
Pros
pect
ive
Mul
ticen
ter
30Tr
ansd
uode
nal-
19/3
0
Tran
sgas
tric
- 11/
3019
GA
. LA
MS
1. 1
0 ×10
mm
- 13/
30
2. 1
5 ×10
mm
- 17/
30
1. L
inea
r ech
oend
osco
pe2.
0.0
35 in
ch g
uide
wire
3. C
ysto
stom
e or b
allo
on
dila
tor
1. M
onito
red
ane
sthes
ia (
prop
ofol
)- 4/
302.
Con
ciou
s s
edat
ion
(fe
ntan
yl an
d m
idaz
olam
)-
26/
30
Med
ian-
15
(ran
ge, 1
3–11
0)
min
LAM
S, lu
men
-app
osin
g m
etal
sten
t; SE
MS,
self-
expa
ndab
le m
etal
sten
t; N
/A, n
ot a
vaila
ble;
EUS-
GBD
, end
osco
pic
ultr
asou
nd-g
uide
d ga
llbla
dder
dra
inag
e; PT
-GBD
, per
cuta
neou
s tra
n-sh
epat
ic g
allb
ladd
er d
rain
age.
461
Jain D et al. EUS-Guided GBD via LAMS
developed hemobilia, which improved with supportive care alone.16
Stent migrationStent migration is a relatively rare complication with LAMS
placement compared to the placement of SEMS or pigtail cath-eters.
Among the 183 patients who underwent EUS-GBD via LAMS, only 2 (1.1%) showed stent migration.7-16 One event occurred on post-procedure day 5 (managed with stent re-trieval and clip closure of the fistula) and the other occurred 8 months post procedure (managed with LAMS replacement).14
MiscellaneousThese complications noted in the composite study cohort
(n=189) included abdominal pain in 1.1% of patients (1 pa-tient developed stent occlusion from a food bolus requiring endoscopic debridement and pigtail stent placement, and the other improved with supportive care alone),7,15 fever in 0.5% (improved with supportive care),11 bile leak with peritonitis in 0.5% (managed with percutaneous drain placement),15 Bou-veret syndrome in 0.5% (treated with endoscopic lithotripsy and stone removal),14 aspiration pneumonia in 0.5% (eventually leading to death)16 and pancreatic infection in 0.5% (eventually leading to death).16
ConCLUSIonS
The absence of an external drainage tube and widespread applicability in patients with coagulopathy or ascites make EUS-GBD using LAMS an attractive option for patients with acute cholecystitis in whom surgery is contraindicated. The procedure demonstrates a high TSR and CSR, although this evidence is based on the few high-volume centers where only a small number of experts perform this procedure. A learning curve has been suggested; however, the minimum training re-quirements are yet to be determined. Complications although rare, are associated with the risk of worsening the clinical situ-ation in already sick patients who are poor surgical candidates. Based on the available evidence, EUS-GBD using LAMS is a safe and efficacious alternative when performed by experts in high-risk surgical patients with acute cholecystitis.
Conflicts of InterestThe authors have no financial conflicts of interest.
Author ContributionsConceptualization: Deepanshu Jain
Data curation: DJ, Bharat Singh Bhandari, Nikhil AgrawalFormal analysis: DJInvestigation: DJ, Shashideep SinghalMethodology: DJProject administration: DJ, SSResources: DJSupervision: DJ, SSValidation: DJ, SS Visualization: DJWriting-original draft: DJ, BSB, NAWriting-review&editing: DJ, SS
REFEREnCES
1. Hassler KR, Jones MW. Gallbladder, cholecystectomy, laparoscopic [In-ternet]. Treasure Island (FL): StatPearls Publishing; c2017 [updated 2017 Oct 16; cited 2018 Apr 12]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448145/.
2. Friedman GD, Raviola CA, Fireman B. Prognosis of gallstones with mild or no symptoms: 25 years of follow-up in a health maintenance organi-zation. J Clin Epidemiol 1989;42:127-136.
3. Garden OJ, Bradbury AW, Forsythe JLR. Principles and practice of sur-gery. 4th ed. Edinburgh: Churchill Livingstone; 2002.
4. Zacks SL, Sandler RS, Rutledge R, Brown RS Jr. A population-based cohort study comparing laparoscopic cholecystectomy and open chole-cystectomy. Am J Gastroenterol 2002;97:334-340.
5. Itoi T, Sofuni A, Itokawa F, et al. Endoscopic transpapillary gallbladder drainage in patients with acute cholecystitis in whom percutaneous tran-shepatic approach is contraindicated or anatomically impossible (with video). Gastrointest Endosc 2008;68:455-460.
6. Widmer J, Alvarez P, Sharaiha RZ, et al. Endoscopic gallbladder drainage for acute cholecystitis. Clin Endosc 2015;48:411-420.
7. de la Serna-Higuera C, Pérez-Miranda M, Gil-Simón P, et al. EUS-guided transenteric gallbladder drainage with a new fistula-forming, lumen-ap-posing metal stent. Gastrointest Endosc 2013;77:303-308.
8. Itoi T, Binmoeller K, Itokawa F, Umeda J, Tanaka R. Endoscopic ultraso-nography-guided cholecystogastrostomy using a lumen-apposing metal stent as an alternative to extrahepatic bile duct drainage in pancreatic cancer with duodenal invasion. Dig Endosc 2013;25 Suppl 2:137-141.
9. Itoi T, Itokawa F, Tsuchiya T, Kurihara T, Tanaka R. Transgastric large gallstone extraction through a lumen-apposing metal stent in a patient with acute cholecystitis. Gastrointest Endosc 2014;79:547.
10. Tharian B, Varadarajulu S, Hawes R. Drainage of obstructed gallbladder with use of lumen-apposing metal stent. Gastrointest Endosc 2016;83:460-461.
11. Irani S, Baron TH, Grimm IS, Khashab MA. EUS-guided gallbladder drainage with a lumen-apposing metal stent (with video). Gastrointest Endosc 2015;82:1110-1115.
12. Kumta NA, Lordello Passos M, Rodela Silva GL, Novikov A, Kahaleh M. Endoscopic ultrasound-guided transmural gallbladder drainage with a lumen-apposing metal stent using an electrocautery enhanced delivery system. Endoscopy 2016;48:E327.
13. Law R, Grimm IS, Stavas JM, Baron TH. Conversion of percutaneous cholecystostomy to internal transmural gallbladder drainage using an endoscopic ultrasound-guided, lumen-apposing metal stent. Clin Gas-troenterol Hepatol 2016;14:476-480.
14. Dollhopf M, Larghi A, Will U, et al. EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an elec-trocautery-enhanced lumen-apposing metal stent device. Gastrointest Endosc 2017;86:636-643.
15. Irani S, Ngamruengphong S, Teoh A, et al. Similar efficacies of endoscopic ultrasound gallbladder drainage with a lumen-apposing metal stent ver-sus percutaneous transhepatic gallbladder drainage for acute cholecysti-tis. Clin Gastroenterol Hepatol 2017;15:738-745.
462
16. Walter D, Teoh AY, Itoi T, et al. EUS-guided gall bladder drainage with a lumen-apposing metal stent: a prospective long-term evaluation. Gut 2016;65:6-8.
17. Binmoeller KF, Shah J. A novel lumen-apposing stent for transluminal drainage of nonadherent extraintestinal fluid collections. Endoscopy 2011;43:337-342.