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Four-Step Classification of Endoscopic Transpapillary Gallbladder Drainage and the Practical Efficacy of
Michihiro Yoshida1, Itaru Naitoh1, Kazuki Hayashi1
1Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
Insights
Cholangioscopic assistance significantly improves the success rate of endoscopic transpapillary gallbladder drainage (ETGBD) for acute cholecystitis. A new classification system helps evaluate technical difficulty and guides the use of cholangioscopy for challenging ETGBD procedures.
Area of Science:
- Gastroenterology
- Minimally Invasive Surgery
- Endoscopic Procedures
Background:
- Acute cholecystitis often requires intervention, with endoscopic transpapillary gallbladder drainage (ETGBD) being an alternative but technically challenging procedure.
- Advanced endoscopic techniques are necessary for ETGBD, and achieving successful drainage can be difficult.
Purpose of the Study:
- To evaluate the efficacy of cholangioscopic assistance in ETGBD procedures.
- To develop a classification system for assessing ETGBD technical difficulty.
- To establish a strategy for optimal cholangioscopy application in difficult ETGBD cases.
Main Methods:
- A retrospective study of 101 patients undergoing ETGBD.
- Comparison of conventional ETGBD (C-ETGBD) with SpyGlass DS-assisted ETGBD (SG-ETGBD).
- Development of a four-step classification for ETGBD procedures and analysis of predictive factors for success.
Main Results:
- Conventional ETGBD (C-ETGBD) achieved a 72.3% success rate.
- SpyGlass DS-assisted ETGBD (SG-ETGBD) had an 84.6% success rate in cases where C-ETGBD failed.
- Optional SG-ETGBD significantly increased the overall success rate to 94.1% (p=0.003).
- SG-assistance was particularly effective in overcoming initial procedural steps like identifying the cystic duct orifice and guidewire advancement.
Conclusions:
- Optional cholangioscopic assistance (SG-ETGBD) significantly enhances the success rate of ETGBD compared to conventional methods.
- The proposed step-based classification aids in assessing ETGBD technical difficulty.
- This classification provides a framework for strategically employing cholangioscopy in challenging ETGBD cases.
Background/Aims:
Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD.
Methods:
A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and SpyGlass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined.
Results:
C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification.
Conclusions:
Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner.
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