EFFICACY AND SAFETY OF LUMEN APPOSING SELF-EXPANDABLE METAL STENTS FOR EUS GUIDED CHOLECYSTECTOMY: AN UPDATED METAANALYSIS AND SYSTEMATIC REVIEW
Saqib Walayat*, Nikhil Kalva, Srinivas R. Puli
Department of Gastroenterology and Hepatology, University of Illinois at Peoria, Peoria, IL
Background:
Early cholecystectomy remains the definitive treatment for patients with acute cholecystitis. Laparoscopic or open cholecystectomy carries high risk for complications in certain patients especially those with multiple comorbidities. Prompt gallbladder drainage (GBD) with percutaneous or endoscopic approach remains a viable therapeutic option for such non-operative candidates. Endoscopic ultrasound (EUS) guided transluminal gallbladder drainage (EUS GBD) has gained significant traction as a viable alternative approach to percutaneous drainage in these situations. However, the recent Tokyo guidelines still favor percutaneous drainage instead of EUS GBD for high-risk surgical patients citing its less invasive nature and lower adverse events. The aim of our updated meta-analysis was to assess the efficacy and safety of EUS GBD with LAMS in non operative candidates with acute cholecystitis. We looked at the technical success, clinical success, overall complication, perforation, recurrent cholangitis, and cholecystitis risk in patients who were deemed surgically unfit for cholecystectomy and underwent EUS GBD.
Methods:
Extensive English language literature search was performed in Medline, Embase, Cochrane central and Google scholar using keywords "endoscopic ultrasound", "stent","gallbladder", "acute cholecystitis" and "cholecystostomy" from Jan 2000 to August 2021. Fixed and random effects models were used to calculate the pooled proportions.
Results:
A total of 22 studies that met the inclusion criteria were included encompassing 992 patients. Pooled proportion of technical success was 97.21%, 95% CI 96.10- 98.13 and clinical success was 92.08%, 95% CI 90.33- 93.67. Overall complication rate was 14.00%, 95% CI 11.92-16.21 and stent related complication rate was 3.00%, 95% CI 2.03- 4.14 in the pooled percentage of patients. Pooled proportion for perforation was noted in 2.02%, 95% CI 1.24- 2.99 of patients. Recurrent cholangitis/cholecystitis was noted in 2.41%,95% CI 1.55- 3.45 of pooled proportion of patients. Pooled estimates were similar using random and fixed models. The Begg Mazumdar indicator for bias gave a Kendall's tau b value of -0.28, p 0.06.
Conclusions :
Our results show EUS GBD with LAMS is a safe and alternative treatment modality for non-operative candidates requiring gallbladder drainage with acceptable intra-procedural and post-procedural complications. These results have important implications for patients as more widespread use of EUS GBD could lead to decrease overall financial burden since EUS GBD has been shown to have shorter length of stay and the need for fewer reinterventions previously. However, more large-scale randomized trials are needed to draw further conclusions.
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