This article is more than 5 years old. Information may no longer be current.
Review highlights emerging endoscopic interventions for gallbladder disease
Click Here to Manage Email Alerts
A new review article examines five interventions for treating gallbladder disease, including recently developed endoscopic approaches.
“Gallstones are common; more than 25 million Americans have gallstones. Each year about 1 million new cases are diagnosed,” Todd H. Baron, MD, professor and director of advanced endoscopy in the division of gastroenterology and hepatology at University of North Carolina School of Medicine, told Healio Gastroenterology. “From this perspective and with the recent technological advances in endoscopic treatments for symptomatic gallbladder disease, we believed that it was important to communicate the potential for recently developed means for managing this common disease to the broader medical community. However, this was also needed within the framework of the other available interventional modalities for gallbladder intervention, along with data from the last 5 years on these treatment modalities.”
Todd H. Baron
Surgical approaches to cholecystectomy include laparoscopic cholecystectomy, which “remains the gold standard of care,” Baron said, and natural orifice transluminal endoscopic surgery, or NOTES.
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy was introduced in 1985 and reduced the need for traditional open surgery. Recent studies have shown early laparoscopic cholecystectomy may be preferred over medical management with delayed laparoscopic cholecystectomy.
The procedure’s advantages may include reduced scarring, postoperative pain, recovery time and wound-related adverse events, but disadvantages include increased risk for postoperative hernias and increased risk for bile-duct injury compared with open cholecystectomy, especially in the event that significant inflammation makes dissection more technically challenging.
Single-incision and mini-laparoscopic cholecystectomy have not been widely accepted because they are expensive and technically demanding, and robotic-assisted laparoscopic cholecystectomy has not been widely accepted for the same reasons and for lack of clinical data and access.
NOTES
NOTES cholecystectomy, introduced in 2007, is performed endoscopically through a naturally existing orifice, most commonly through the transvaginal route. The procedure does not require an abdominal wall incision, which can reduce postoperative pain and complications, and it is associated with superior aesthetic outcomes and shorter recovery time. It is technically challenging and requires special equipment, so it is only available in a small number of medical centers.
“In very select centers and in selected patients with symptomatic cholelithiasis without cholecystitis, [NOTES] is an alternative to laparoscopic cholecystectomy,” Baron said.
Percutaneous cholecystectomy
Percutaneous cholecystectomy was introduced as an alternative to laparoscopic cholecystecomy in 1980, and from 1994 to 2009 it has increased from 0.3% to 2.9% of gallbladder procedures in the Medicare population. It successfully treats an estimated 90% of acute cholecystitis patients but adverse events occur in up to 25%, including catheter dislodgement and discomfort of cholecystostomy tubes. A large randomized trial of laparoscopic cholecystectomy and percutaneous cholecystostomy is currently underway.
“Percutaneous cholecystostomy, useful as a bridge to cholecystectomy in selected patients, is not a good long-term management option in poor surgical candidates,” Baron said.
Transpapillary and transmural drainage
“Endoscopic transoral therapies avoid percutaneous drains and are reserved for patients who are not candidates for cholecystectomy,” Baron said.
Endoscopic drainage of the gallbladder through the transpapillary route guided by endoscopic retrograde cholangiography (ERCP) was introduced over 25 years ago, and effectively treats over 90% of cholecystitis patients when performed successfully. The procedure is technically challenging and has therefore not been widely adopted.
“The most recent approach to symptomatic cholelithiasis, EUS-guided peroral transenteric gallbladder drainage (transgastric or transduodenal stent placement) may be a better long-term solution than percutaneous drainage for gallbladder disease,” Baron said. “However, the procedure is not yet widely available and more comparative data are needed to support its use.”
Transmural drainage of the gallbladder guided by endoscopic ultrasound (EUS) was introduced in 2007 and successfully treats over 95% of high-risk acute cholecystitis patients, but possible adverse events include perforation, bleeding and intraperitoneal bile leakage. Data on the procedure are limited, and questions remain regarding stent removal and possible interference with subsequent surgeries caused by adherence of the gallbladder to the stomach or duodenum.
Baron and colleagues “anticipate significant potential for growth in [the transmural approach] as the technology continues to evolve, and performing the technique becomes both easier and faster,” according to a press release.
The authors concluded that “the decision as to whether cholecystectomy or gallbladder drainage is more appropriate for a patient with symptomatic gallbladder disease should be based on the severity of the acute illness, the patient’s overall health, and the locally available expertise and technology.” – by Adam Leitenberger
Disclosure: Baron reports receiving consulting fees from Boston Scientific, Cook Endoscopy, Olympus America, W.L. Gore and ConMed, travel support from Xlumena and grant support from Cook Endoscopy. Please see the full study for a list of all other authors’ relevant financial disclosures.
Editor’s Note: This article was updated on July 27 to reflect additional information.
Click Here to Manage Email Alerts