Danielle Hayes, MD, Gary Lucas, MD, Bryce French, MD, Andrew Discolo, MD, Rajnish Mishra, MD, Sean Wells, MD. Swedish Medical Center – First Hill
Introduction: Cholecystectomy is the gold standard treatment of acute cholecystitis. Patients with multiple comorbidities who are considered high-risk surgical candidates are commonly recommended to undergo percutaneous cholecystostomy tube placement; however, long-term external drainage is undesirable for many patients. Endoscopic transpapillary stent placement (ETSP) has been described as an alternative method for decompression of the gallbladder. The purpose of our study is to assess which patients would benefit from this treatment compared to traditional treatments of cholecystitis.
Methods: We performed a retrospective chart review of patients with cholecystitis who underwent ETSP at our institution between January 2015 and July 2018. This study was performed to identify indication, comorbidities, length of stay, labs, outcomes, additional procedures, and whether cholecystectomy was eventually performed.
Results: During the study period, 12 patients underwent ETSP. The mean age was 68.2 years (± SD 12.4) with an average ASA class of 3.2. The Charlson Comorbidity Index was greater than seven in 75% of patients, indicating a zero percent 10-year survival. The NSQUIP surgical risk calculator estimated an average mortality risk for laparoscopic cholecystectomy of 4.8% (± 3.3, 95% CI) in our study population; the estimated risk in the general population is 0.1%. Resolution of symptoms with endoscopic drainage was achieved in 11 of 12 patients (91.7%); one patient experienced no symptom resolution with endoscopic drainage nor subsequent percutaneous cholecystostomy tube placement. Six of 12 patients underwent interval cholecystectomy.
Adverse events occurred in four cases which consisted solely of post-ERCP stent migration or occlusion. Estimated time to stent occlusion or migration ranged from 20-400 days. Two patients died in the time of the study, one from sepsis in the setting of metastatic pancreatic cancer and the second from biliary sepsis after stent migration.
Conclusion: Endoscopic transpapillary stent placement is an effective and safe method for the temporary management of acute cholecystitis in high risk surgical patients. We recommend attempting ETSP as a temporizing measure for acute cholecystitis in high risk surgical patients who are undergoing ERCP for other diagnostic or therapeutic purposes and patients with anatomy that would make percutaneous cholecystostomy tube placement challenging. Randomized studies would be helpful to further investigate the utility and safety of ETSP in the management of acute cholecystitis.
Keywords: Endoscopic Transpapillary Stenting; Cholecystitis; Gallbladder Drainage; Percutaneous Cholecystostomy Tube; Cholecystectomy
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94302
Program Number: P226
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster