Percutaneous cholecystoenteric anastomosis for non-surgical patients with indwelling chole tube

A Pilot Study of Percutaneous Cholecystoenteric Anastomosis: A New Option for High-Risk Patients with Symptomatic Gallstones

Clinical Question

Is percutaneous cholecystoenteric anastomosis creation via lumen-apposing metal stent safe and effective in patients with indwelling cholecystostomy tubes who are otherwise high-risk for surgical interventions?

Take Away Point

Cholecystoenteric anastomosis creation via stent placement demonstrated 100% technical success rate with a mean follow-up time of 15 months and 86% clinical success rate with subsequent removal of indwelling cholecystostomy tubes within 36 days.

Reference

Barragan C, Alshehri H, Marom G, Glazer Y, Swanstrom L, Shlomovitz E. A pilot study of percutaneous cholecystoenteric anastomosis: A new option for high-risk patients with symptomatic gallstones. Journal of Vascular and Interventional Radiology. 2023;35:74-79. doi:10.1016/j.jvir.2023.09.025

Link to article

Study Design

Retrospective and observational study consisting of 14 patients

Funding Source

No reported funding

Setting

Academic, University Health Network, Toronto, Canada
Academic, The Hebrew University of Jerusalem, Jerusalem
Public and Private, Institut de Chirurgie guidée par l’Image, Strasbourg, France

Figure

Summary

Acute calculus cholecystitis is a very common pathology in the United States, leading to over 200,000 cases of admissions annually. While laparoscopic cholecystectomy remains the gold standard, patients who are poor surgical candidates generally receive alternative management such as percutaneous cholecystostomy tube placement. However, these options expose patients to risks and complications in the long-term including infection, pain and tube dislodgement along with impairment in their quality of life.

The authors of this paper studied the safety and effectiveness of percutaneous cholecystoenteric anastomosis creation. They performed a retrospective analysis consisting of fourteen patients (10 male and 4 female) with indwelling cholecystostomy tubes, all of whom were high risk for surgery or percutaneous stone removal procedure. Technical success was defined as stent placement across the percutaneously created cholecystoduodenal anastomosis, while clinical success was defined as successful removal of any cholecystostomy drain after stent placement.

The results of the study demonstrated 100% technical success rate with a mean follow-up time of 15 months. Axios stents (Boston Scientific, Marlborough, Massachusetts) were utilized in 12/14 patients. Clinical success rate was 86% with a mean duration to cholecystostomy tube removal of 36 days (9 of whom had their tubes removed within 30 days). The remainder two patients included one death secondary to comorbid cardiac medical history and one lost to follow-up. The study reported no device-related adverse events.

This data demonstrated highly favorable results of percutaneous cholecystoenteric anastomosis creation using lumen-apposing metal stent. The advantages of this technique include no requirement for general anesthesia or endoscopy, improvement in quality of life, and prevention of tube-related complications (occlusion, tube dislodgement, pain, etc). The drawbacks include reliance on 2-dimensional representation of a 3-dimensional structure for puncture guidance and reliance on the pre-existing cholecystostomy tube access, and potential malpositioned stent across the cholecystoenteric tract.

The first limitation of the study is the evolving nature of the technique. Secondly, there is limited long-term data on the effects of stent placement across a cholecystoenteric anastomosis. Lastly, combination of this technique with existing gallstone management strategies remain unstudied.

Commentary

Percutaneous cholecystoenteric anastomosis creation with lumen-apposing metal stent is a novel technique that shows promising data in improving quality of life for high-risk patients with indwelling cholecystostomy tubes. However, more data is still needed, particularly on the generalizability of the procedure, long-term effects of the procedure, and comparative advantages to existing gallstone management strategies. This pilot study has laid the groundwork for future larger, multi-centered, preferably randomized comparative studies and may revolutionize gallstone management in high-risk non-surgical patients.

Post author

Naeem Patel, DO
Radiology Resident, PGY4
Department of Radiology, Interventional Radiology Division
Hartford Hospital, Hartford, CT
@Naeemp7Patel