Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA.
Gastrointest Endosc. 2019 Sep;90(3):483-492. doi: 10.1016/j.gie.2019.04.238. Epub 2019 May 2.
There is an evolving role for EUS-guided transmural gallbladder (GB) drainage. Endoscopic transpapillary GB drainage is a well-established, nonoperative treatment for acute cholecystitis. We compared the outcomes of 78 cases of EUS-guided versus transpapillary GB drainage at a single, U.S.-based, high-volume endoscopy center.
This was a retrospective analysis performed from May 2013 to January 2018, identified from a database of nonoperative patients with acute cholecystitis. Both electrocautery-enhanced and nonelectrocautery-enhanced lumen-apposing metal stents were used. For transpapillary drainage, guidewire access was obtained and then a transpapillary 7F × 15-cm double-pigtail plastic stent was placed.
In patients who had successful transpapillary or transmural drainage, demographics data were similar. Technical success was observed in 39 of 40 patients (97.5%) who underwent first attempt at EUS-guided drainage versus 32 of 38 patients (84.2%) for first-attempt transpapillary drainage (adjusted odds ratio, 9.83; 95% confidence interval, .93-103.86). Clinical success was significantly higher with EUS drainage in 38 of 40 patients (95.0%) versus transpapillary drainage in 29 of 38 patients (76.3%) (adjusted odds ratio, 7.14; 95% confidence interval, 1.32-38.52). Recurrent cholecystitis was lower in the EUS-guided drainage group (2.6% vs 18.8%, respectively; P = .023) on univariate analysis but only trended to significance in a multiple regression model. Duration of follow-up, reintervention rates, hospital length of stay, and overall adverse event rates were similar between groups.
EUS-guided GB drainage results in a higher clinical success rate compared with transpapillary drainage and may be associated with a lower recurrence rate of cholecystitis. However, transpapillary drainage should be considered as the first-line treatment for patients who are surgical candidates but require temporizing measures or require an ERCP for alternative reasons.
超声内镜（EUS）引导下经壁胆囊（GB）引流的作用不断发展。内镜经乳头胆囊引流是一种成熟的非手术治疗急性胆囊炎的方法。我们比较了在一家美国高容量内镜中心进行的 78 例 EUS 引导与经乳头 GB 引流的结果。
这是一项回顾性分析，于 2013 年 5 月至 2018 年 1 月期间从数据库中识别出非手术治疗的急性胆囊炎患者。使用了电烧增强和非电烧增强的管腔贴合金属支架。对于经乳头引流，先获得导丝通道，然后放置经乳头 7F×15cm 双猪尾塑料支架。
在成功进行经乳头或经壁引流的患者中，人口统计学数据相似。在首次尝试 EUS 引导引流的 40 例患者中，技术成功率为 39 例（97.5%），而首次尝试经乳头引流的 38 例患者中，技术成功率为 32 例（84.2%）（调整后的优势比，9.83；95%置信区间，.93-103.86）。在 40 例患者中，EUS 引流的临床成功率明显高于经乳头引流的 29 例（95.0%比 76.3%）（调整后的优势比，7.14；95%置信区间，1.32-38.52）。在单变量分析中，EUS 引导引流组复发性胆囊炎发生率较低（分别为 2.6%和 18.8%，P=0.023），但在多变量回归模型中仅呈趋势。两组之间的随访时间、再干预率、住院时间和总体不良事件发生率相似。
EUS 引导下 GB 引流与经乳头引流相比，临床成功率更高，可能与胆囊炎复发率较低有关。然而，对于有手术适应证但需要临时措施或因其他原因需要 ERCP 的患者，应考虑经乳头引流作为一线治疗方法。
