Conversion of percutaneous cholecystostomy to transmural endoscopic ultrasound-guided gallbladder drainage in malignant biliary obstruction

Background: In patients with distal malignant biliary obstruction, it is a challenge to manage acute cholecystitis secondary to cystic duct obstruction associated with tumor progression or stent compression. Percutaneous transhepatic gallbladder drainage (PTGBD) has been used as the treatment option of choice, because of its ease of performance and safety, but because of the use of an external drainage tube, some patients experience a decreased quality of life. We report the technical success and clinical success of conversion from PTGBD to endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) for the treatment of acute cholecystitis in patients with unresectable malignant biliary obstruction. Methods: We included the patients with cholecystitis secondary to unresectable malignant biliary obstruction who underwent conversion from PTGBD to EUS-GBD in the study. After PTGBD for the treatment of acute cholecystitis, we performed EUS-GBD and a plastic stent or a self-expandable metal stent (SEMS) was placed for fistulostomy. Results: Fourteen patients (median age, 69 years; 9 males and 5 females) underwent conversion to EUS-GBD after clinical improvement of cholecystitis by PTGBD. The technical success rate of the conversion from PTGBD to EUS-GBD was 100% (14/14). EUS-GBD was performed in a median of 9.5 days (range, 3-51 days) after PTGBD procedure, using mainly a plastic stent (13 patients) and a covered SEMS in one patient. The early (within 24 hours) adverse events rate was 14.3% (2/14), and the late (after 24 hours) adverse events rate was 7.1% (1/14). The rate of recurrence of cholecystitis was 28.6% (4/14). These patients underwent endoscopic re-intervention and there were no cases of further recurrence of cholecystitis. Conclusion: Conversion of PTGBD to EUS-GBD demonstrated a feasible and safe technique for acute cholecystitis in non-surgical candidates with malignant biliary obstruction. Copyright (C) 2019, Society of Gastrointestinal Intervention.