Nonsurgical Gallbladder Drainage: Percutaneous and Endoscopic Approaches

Acute cholecystitis is a common condition affecting 500,000 Americans per year. Although the gold standard treatment is cholecystectomy, some patients are poor surgical candidates requiring alterna-tive treatment. Alternative treatment usually involves gallbladder drainage through a percutaneous or endoscopic approach. One common endoscopic approach is the transpapillary approach which involves cannulating the common bile duct and cystic duct sequentially and inserting a stent into the gallbladder. This technique can be technically challenging as the cystic duct can be difficult to cannulate and has a risk of postprocedure pancreatitis. However, this technique can be advantageous as it pre -serves a patient's anatomy for possible surgery in the future. The other common endoscopic approach is the transmural approach. This involves using an echoendoscope to determine an appropriate place to puncture the gallbladder and then using a needle and guidewire to create an opening to place a stent connecting the gallbladder and GI lumen. Use of a needle and guidewire can be obviated if an electro-cautery method is used. This technique has an exceptionally high technical and clinical success rate but there is concern for stent occlusion and tissue overgrowth in long term stent placement. Technical and clinical success rates are similar between the percutaneous and transmural approaches which are higher than those in the transpapillary approach. Taken together, the endoscopic approaches are associated with shorter hospital stays and readmissions. Mortality rates are similar in all the approaches.