Efficacy and Safety of Lumen Apposing Self-Expandable Metal Stents for EUS Guided Cholecystostomy: A Meta-Analysis and Systematic Review

Abstract

Background Patients with acute cholecystitis are treated with early cholecystectomy. A subset of patients are unfit for surgery due to comorbidities and late presentation. Prompt gall bladder drainage (GBD) with percutaneous or endoscopic approach remains a viable therapeutic option for nonoperative candidates. Endoscopic ultrasound (EUS) guided transluminal gall bladder drainage (EUS-GBD) continues to evolve as an alternative approach to percutaneous drainage. With continued refinement in stent technology, lumen apposing self-expandable metal stent (LAMS) offers several advantages. We performed a pooled analysis on the efficacy and safety of EUS-GBD with LAMS in nonoperative candidates with acute cholecystitis. Methods Extensive English language literature search was performed in Medline, Embase, Cochrane Central, and Google Scholar using keywords “endoscopic ultrasound”, “stent”, “gallbladder”, “acute cholecystitis”, and “cholecystostomy” from Jan 2000 to Dec 2016. Fixed and random effects models were used to calculate the pooled proportions. Results Data was extracted from 13 studies that met the inclusion criteria (n = 233). Pooled proportion of technical success was 93.86% (95% CI = 90.56 to 96.49) and clinical success was 92.48% (95% CI = 88.9 to 95.42). Overall complication rate was 18.31% (95% CI = 13.49 to 23.68) and stent related complication rate was 8.16% (95% CI = 4.03 to 14.96) in the pooled percentage of patients. Pooled proportion for perforation was 6.71% (95% CI 3.65 to 10.6) and recurrent cholangitis/cholecystitis was noted in 4.05% (95% CI = 1.64 to 7.48). Publication bias calculated using Harbord-Egger bias indicator gave a value of −0.61 (95% CI = −1.39 to 0.16, p = 0.11). The Begg-Mazumdar indicator for bias gave Kendall's tau b value of −0.42 (p ≥ 0.05). Conclusions EUS-GBD with LAMS is a safe and alternative treatment modality for patients needing gallbladder drainage, with acceptable intraprocedural and postprocedural complications. However, due to the limited data and lack of direct comparison with other methods, further controlled trials are necessary to estimate the overall efficacy and safety and the role of EUS-GBD with LAMS in management of nonoperative patients with acute cholecystitis.

Introductory Chapter: Endoscopy-Novel Techniques and Recent Advancements

“…Along with the additional growth of the industry of endoscopy supplies, EUS has enabled novel therapeutic alternatives. Lumen-apposing metal stents are highlighting a fine line between the gastroenterology and surgical community [60] (Figure 5A, B). EUS-guided gallbladder drainage [61], EUS-choledochoduodenostomy [62], EUS-pancreaticogastrostomy [63], and the most recent EUS-gastrojejunostomy [64] represent some of the challenges that were introduced with focus on minimally invasive therapy.…”

Endoscopic ultrasound guided gallbladder drainage - is it ready for prime time?

“…Most common complications of EUS guided gallbladder drainage are transient abdominal pain, pneumoperitoneum, biliary peritonitis, and stent migration requiring repeat intervention[19]. Bleeding occurs in up to 13% and stent migration in up to 8% of the patients[20].…”

Endoscopic transpapillary gallbladder drainage for the management of acute calculus cholecystitis patients unfit for urgent cholecystectomy

“…Recently, lumen apposing metal stents (LAMS), which have saddle-shaped design with flared ends and wide inner lumen, have been used for EUS-GBD and may reduce the risk of procedure-related complications, including stent migration or bile leakage. In a recent systematic review, the technical success rate, clinical success rate, and adverse events rate of EUS-GBD with a LAMS was 95.2%, 96.7%, and 8.8%, respectively [16,17]. Nevertheless, interventional endoscopic experts are required, and the relatively high procedural costs may be challenging.…”