Draining the Gallbladder -- Endoscopy brings new options.

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In April, Jang and colleagues published in Gastroenterology an article titled:  Endoscopic ultrasound-guided transmural and percutaneous transhepatic gallbladder drainage are comparable for acute cholecystitis.  In this potentially practice changing study, they conducted a prospective randomized trial comparing conventional percutaneous drainage of the gallbladder to EUS-guided transmural drainage.  The procedure involved accessing the gallbladder through the duodenal bulb or prepyloric antrum.  Through this access point, serial dilators are placed and then a nasobiliary drain.  Sedation involved midazolam and meperidine.  With 30 patients per group, they found not significant difference in complications and "successful" control of cholecystitis.  Conversion to open cholecystectomy was also similar in both groups.  Placement of the transmural nasobiliary drain took less than 30 minutes.  


Despite the novelty of this procedure and less pain with the endoscopic approach, current evidence does not support its use in patients that can tolerate an operation. Importantly, if general anesthesia is required for the endoscopic procedure, then why not perform a lap chole.  I feel a key aspect of this manuscript is the use of a nasobiliary drain.  It acts as reminder that the gallbladder needs to come out at some point.  With recent use of transpapillary drainage of the gallbladder with double pigtail drains, physicians might get the false impression that drainage is all that is required.  The authors highlight that flushing of the nasobiliary drain was required and bile output measured.  As we learned with transgastric drains for pancreatic pseudocysts, drains occlude and secondary procedures may be required.  


Jang and colleagues fail to mention one benefit of the percutaneous drain.  After maturation of the track, additional procedures can be performed by interventional radiology via the cholecystostomy tube.  The acute angles of the nasobiliary drain may prevent access to the biliary tree or stone extraction.

Although laparoscopic cholecystectomy is the standard for managing acute cholecystitis, we now have one more option for managing this disease.  With wider application, we will see if it remains a safe option.