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Risk Factors and Treatment Strategies for Cholecystitis After Metallic Stent Placement for Malignant Biliary Obstruction
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND AND STUDY AIMS
Cholecystitis can occur after self-expandable metallic stent (SEMS) placement for malignant biliary obstructions (MBO). Furthermore, the best treatment option for cholecystitis has not been determined. Here, we aimed to identify the risk factors of cholecystitis after SEMS placement and determine the best treatment option.
PATIENTS AND METHODS
Incidence, treatments, and predictive factors of cholecystitis were retrospectively evaluated in 1,084 patients with distal MBO (DMBO) and 353 patients with hilar MBO (HMBO) who underwent SEMS placement at the 12 institutions from January 2012 to March 2021.
RESULTS
Cholecystitis occurred in 7.5% of patients with DMBO and 5.9% of patients with HMBO. The recurrence rate was significantly lower (p=0.043), and the recurrence-free period was significantly longer (p=0.039) in endoscopic procedures than in percutaneous procedures for cholecystitis treatment. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was better in terms of technical success, procedure time, and recurrence-free period than endoscopic transpapillary gallbladder drainage. The cases with obstruction across the cystic duct orifice by tumor (p=0.015) and those with obstruction by stent (p=0.037) were the independent risk factors for cholecystitis in DMBO. The cases with multiple SEMS placements (OR 11, 95% CI 0.68-190, p=0.091) and those with gallbladder stones (OR 2.3, 95% CI 0.92-5.6, p=0.075) had a higher risk for cholecystitis in HMBO.
CONCLUSIONS
The incidences of cholecystitis after SEMS placement for DMBO and HMBO were comparable. EUS-GBD is the optimal treatment option for patients with cholecystitis after SEMS placement for MBO.
Additional Info
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Risk factors and treatment strategies for cholecystitis after metallic stent placement due to malignant biliary obstruction: a multicenter retrospective study
Gastrointest. Endosc. 2024 Mar 13;[EPub Ahead of Print], A Matsumi, H Kato, T Ogawa, T Ueki, M Wato, M Fujii, T Toyokawa, R Harada, Y Ishihara, M Takatani, H Tsugeno, N Yunoki, T Tomoda, T Mitsuhashi, M OtsukaFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
We commend Matsumi and colleagues for conducting a large multicenter retrospective study analyzing the risk factors and treatment strategies for cholecystitis after metal stent placement in cases of malignant biliary obstruction (MBO). Over a 9-year period, 12 centers in Japan evaluated 1437 individuals (distal, 1084; hilar, 353) undergoing stent placement. The type of self-expandable metallic stent (SEMS) was at the discretion of the operator, although uncovered SEMS were almost exclusively used for hilar obstruction (97%) with a partial stent-in-stent technique when multiple stents were needed.
The overall incidence of cholecystitis was 7.5% and 5.9% in distal and hilar MBO, respectively. The majority of studies to date have examined distal MBO, and a handful of studies have compared covered versus uncovered SEMS placement with mixed results.1–4 Matsumi and colleagues studied several variables showing that the median time to cholecystitis occurred earlier in hilar versus distal MBO (11 vs 69 days). Independent risk factors for distal MBO were tumor obstruction and stent obstruction along the cystic duct orifice. The authors extend the current literature by demonstrating risk factors in cases of hilar MBO. Multivariate analysis demonstrated that patients with hilar obstruction who had multiple SEMS placed and presence of gallstones were at increased risk of cholecystitis.
Matsumi et al also evaluated the outcomes of the different endoscopic and percutaneous treatments offered to this cohort. This is a growing area of interest as there is no clear consensus guideline on the optimal management strategy for cholecystitis in MBO after SEMS placement. The two endoscopic procedures include endoscopic ultrasonography–guided gallbladder drainage (EUS-GBD) and endoscopic transpapillary gallbladder drainage (ETGBD), while percutaneous approaches involved percutaneous transhepatic gallbladder drainage and percutaneous transhepatic gallbladder aspiration. Although there was no major difference in technical success, clinical success, or adverse events, the endoscopic methods were associated with longer recurrence-free periods compared with the percutaneous methods (96 vs 36 days). The EUS-GBD group (n = 29) outperformed ETGBD (n = 4) in terms of technical success (97% vs 75%), procedure time (25.5 vs 49.5 min), and recurrence-free period (96 vs 36 days); however, the number of cases in these groups was not comparable. This is a known and expected outcome owing to the challenges associated with going through the mesh of a SEMS and our method of choice in treating cholecystitis with a SEMS covering the cystic duct orifice. EUS-GBD exhibited higher rates of adverse events (n = 5) compared with none in ETGBD; however, the overall number was too small to analyze and probably included the early experience of EUS-GBD given that the study spanned 9 years. Several comparative studies including a meta-analysis have shown no significant difference in the adverse event rates between EUS-GBD and ETGBD, with significantly higher success rates, especially if traversing a metal stent is needed.5
Understanding the risk factors that increase the occurrence of cholecystitis is important in patients with MBO and is an understudied topic. One data point lacking in the present study was the bile duct diameter at the cystic duct take-off. We feel that the risk of cholecystitis is much higher with any SEMS (covered more likely than uncovered) that were to overlap the cystic duct in a smaller-caliber bile duct than a capacious one, given the pressure exerted at its insertion site; whereas, a capacious bile duct, well above 10 mm, should allow an adequate flow of bile even when a covered SEMS is used. We feel this is an important criterion that almost none of the comparative studies have looked at regarding the risk of cholecystitis post SEMS placement, and we encourage future studies to look at this important variable.
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