Peroral cholecystoscopy using a multibending ultraslim endoscope through a lumen-apposing metal stent for endoscopic ultrasound-guided gallbladder drainage: a feasibility study

• Introduction
• Methods
• Patients
• Multibending ultraslim endoscope
• Procedures
• Outcomes
• Results
• Discussion
• Funding
• References

Abstract

Background Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) has rendered endoscopic gallbladder assessment through a stent possible, but an appropriate endoscope is required. We assessed the feasibility of peroral cholecystoscopy (POCC) using a multibending ultraslim endoscope passed through a LAMS after EUS-GBD.

Methods 14 patients with a LAMS for EUS-GBD who consecutively underwent POCC were included. POCC was performed using a multibending endoscope inserted through the LAMS. The primary outcome was the technical success rate, defined as complete endoscopic examination of the gallbladder from the orifice of the cystic duct to the fundus. The types of intervention and adverse events were recorded.

Results 17 POCCs were performed in 14 patients. Of the 17 POCCs, 15 (88.2 %) were technically successful. Narrow-band imaging endoscopy was performed in 12 procedures (70.6 %), and cholecystoscopy-guided target biopsies were obtained in six. Gallstone extraction was performed in two patients. After POCC, all LAMSs remained stable and no adverse events were observed.

Conclusions POCC using a multibending ultraslim endoscope can be effectively and safely performed through a LAMS after EUS-GBD.

Introduction

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) can provide a port for additional cholecystoscopic procedures [1] [2]. To the best of our knowledge, only two studies and a few case reports of gallbladder observation and procedures performed through a LAMS have been published [3] [4] [5] [6]. In previous studies, conventional gastroscopic endoscopes were used to perform the cholecystoscopic examinations through the LAMS. As the gallbladder is small, narrow, and elongated, peroral cholecystoscopy (POCC) using a conventional endoscope may allow only limited evaluation.

Recently, the use of a prototype multibending ultraslim endoscope has afforded high rates of technical success and has reduced the procedural times for direct peroral cholangioscopy [7]. We expected the new multibending endoscope would also be suitable for gallbladder examination. Therefore, we explored the feasibility of POCC using a multibending endoscope inserted through a LAMS after EUS-GBD.

Methods

Patients

Data were collected through a retrospective review of patients treated at a single tertiary referral hospital between July 2016 and June 2019. Patients undergoing EUS-GBD using a LAMS who also underwent consecutive POCC were included. The indications for POCC were: (1) diagnosis of combined neoplastic disease or stone in the gallbladder; (2) evaluation of tumor extension in the gallbladder; (3) endoscopic removal of a stone on direct visualization.

The study was approved by the institutional review board of SoonChunHyang University of Bucheon Hospital.

Multibending ultraslim endoscope

The multibending endoscope (CHF-Y0010; Olympus Medical Systems, Co., Ltd., Tokyo, Japan) was used to perform POCC after EUS-GBD. This is a modified ultraslim endoscope developed for direct peroral cholangioscopy, featuring a standard forward-viewing reusable upper gastrointestinal endoscope that can facilitate diagnostic and therapeutic interventions. The multibending endoscope is 133 cm in length. The outer diameters of the distal end and the insertion tube are 4.9 and 7.0 mm, respectively. The thick insertion tube improves the “pushability” of the ultraslim endoscope. The prototype has two bending sections. Both the proximal and distal sections can be deflected in a single plane. The angulation of the distal section ranges from 200° upward and 100º downward. For the proximal section, the attainable angulations are 90º both upward and downward. The two bending sections enable acute angulation of the distal tube. The multibending endoscope has two working channels with diameters of 2.2 and 1.0 mm (Fig. 1 s, see online-only Supplementary material). A detailed comparison of the multibending endoscope with a commonly used conventional ultraslim endoscope and a gastroscope is given in Table 1 s.

Procedures

We performed a two-stage procedure. Once EUS-GBD had been technically successfully performed, we performed POCC through the LAMS. EUS-GBD was performed using fully covered, self-expandable metal stents (Niti-S SPAXUS or Niti-S Hot SPAXUS; Taewoong Medical Co. Ltd., Ilsan, South Korea). The procedure was performed as previously described (Fig. 2 s) [8].

POCC was performed with the LAMS in place. The multibending endoscope was inserted into the gallbladder through the LAMS under carbon dioxide insufflation. The gallbladder was first examined using white-light imaging and was re-evaluated with narrow-band imaging (NBI) if an abnormal mucosal lesion was detected. Biopsy was performed using 5-Fr forceps if the operator deemed it necessary. For patients with stones, a 5-Fr lithotomy basket was used for stone removal. Multiple POCCs were performed to confirm clearance of stones or evaluate progression of malignancy.

Outcomes

The primary outcome was the technical success rate of POCC. Technical success was defined as complete endoscopic examination of the gallbladder from the orifice of the cystic duct to the fundus ([Fig. 1]). The technical success was thoroughly reviewed based on the images, and videos of all cases.

The secondary outcomes were the success rate of any endoscopic interventions under direct visualization and the number and types of procedure-related adverse events, such as recurrent cholecystitis, stent migration, perforation, and air embolism. The adverse events were monitored and graded using the criteria of the American Society for Gastrointestinal Endoscopy [9]. Adverse events were categorized as intraprocedural, early (≤ 24 hours from the procedure), or late (> 24 hours after the procedure).

Results

A total of 17 POCCs were performed in 14 patients ([Table 1]). POCC was performed at a median of 7 (interquartile range 2–14) days after the index EUS-GBD. The most common etiology of acute cholecystitis was malignant cystic duct obstruction. Three patients underwent EUS-GBD via an electrocautery-enhanced delivery system. The diameters of the LAMSs placed were 10 mm in 12 patients and 8 mm in 2 patients. POCC was technically successful in 15 procedures (88.2 %). In two cases, complete endoscopic examination was not possible because of food impaction in the gallbladder, despite vigorous irrigation.

Diagnostic and therapeutic interventions were performed under direct visualization as necessary ([Table 2]). NBI was performed in 12 patients with abnormal gallbladder mucosal lesions. Cholecystoscopy-guided target biopsies were performed under white-light imaging and NBI in six patients. Of these, two patients exhibited acute inflammation with ulcers; the other four patients had nodular, papillary, or depressed lesions on endoscopic imaging, which were revealed to be adenocarcinomas on pathology ([Fig. 2]). In two patients, gallstones of 2–6 mm were evident. The stones were removed using a basket under direct visualization ([Video 1]). After confirmation of stone clearance, the LAMS was removed using rat-toothed forceps in one patient.

Video 1 Removal of gallbladder stones under direct visualization through a lumen-apposing metal stent.

We encountered no procedure-related adverse events, such as recurrent cholecystitis, stent migration, perforation, or air embolism, during or after POCC, and no recurrent cholecystitis after LAMS insertion.

Discussion

Many attempts have been made to access and examine the inner part of the gallbladder through percutaneous endoscopic routes or peroral routes employing a mother–baby scope [10] [11]. Recently, examination of the gallbladder using the Spyglass direct visualization system (Boston Scientific, Natick, Massachusetts, USA) through a transpapillary approach has been reported, but only gallbladder visualization (not any subsequent intervention) was possible, with unsatisfactory image quality [12] [13] [14].

More recently, gallbladder drainage through a LAMS has achieved high technical and clinical success rates [15]. The fistula created by the LAMS renders it technically simple to access the gallbladder to perform further diagnostic and therapeutic procedures [4].

We found that the multibending endoscope, which is effective in direct peroral cholangioscopy, was also useful in POCC through a LAMS owing to its robust structure [7]. The slim distal diameter (5 mm) renders it easy to advance and withdraw the endoscope through the LAMS, regardless of the stent diameter. The two bending sections that enable acute angulation within a narrow lumen facilitate fundal and cystic duct evaluation ([Fig. 1]). The thicker diameter of the insertion tube prevents loop formation. POCC using the multibending endoscope was feasible and safe, with a high technical success rate (88.2 %) and without any intra- or post-procedural adverse events.

Our technical success rate was similar to that reported in previous studies. One study using an AXIOS stent (Boston Scientific) reported a technical success rate of 93.1 % and an adverse event rate of 3.8 % after POCC [3]. In this study, POCC was performed using a larger diameter endoscope (GIF-H290Z; Olympus Medical Systems) to allow magnification of mucosal lesions. In our study, NBI was used for detailed examinations of lesions and was helpful for detecting malignancies. NBI may also be useful for clinical gallbladder inspection. Chan et al. [3] also performed various interventions including gallbladder laser lithotripsy and polypectomy. We expect that multibending endoscope will also facilitate these advanced procedures with specific accessories.

One case study reporting POCCs after EUS-GBD for acute cholecystitis incidentally identified a gallbladder adenocarcinoma that was undetectable on computed tomography scanning [6]. POCC performed through the fistula created by a LAMS enables early detection of gallbladder disease under direct visualization.

Previous studies have not defined the POCC technical success criteria in detail. POCC was performed at least 1 month after LAMS insertion, to prevent stent migration. In contrast, we performed most POCCs 1 week after the index EUS-GBD. The use of this new, slender, flexible endoscope decreases the risk of stent migration and we saw no stent migration after POCC in a short-term period from the index EUS-GBD. In earlier studies, most LAMSs were removed before and after POCC; however, we removed the LAMSs of only two patients considering the low life expectancies of the patients. No additional adverse events induced by the LAMSs were observed during follow-up.

Our study had certain limitations. First, it was retrospective in nature, with a small number of patients, a short follow-up period, and lacked a control group. Because of the absence of a direct comparison with other endoscopes, it is difficult to conclude that the multibending endoscope is better for the POCC than other conventional endoscopes. There was no well-documented protocol owing to the retrospective design of our study, which could make the results of this study less reliable and a well-documented further prospective study is needed to confirm our result. In addition, because the main purpose of this study was to evaluate the feasibility of POCC using the multibending endoscope, further exploration is required of the appropriate indications for POCC.

Until now, EUS-GBD using a LAMS has been available in only a few centers. Its cost is higher than that of percutaneous cholecystostomy, but the upside is that advanced cholecystoscopic diagnostic and therapeutic approaches are possible. The cost-effectiveness of combined EUS-GBD/POCC should be evaluated.

In conclusion, POCC performed using a multibending ultraslim endoscope for gallbladder examination and interventions is effective and safe through a LAMS after EUS-GBD. Further prospective studies with larger number of patients are warranted.

Funding

SoonChunHyang University Research Fund

Competing interests

The authors declare that they have no conflict of interest.

Acknowledgments

We thank Olympus Medical systems (Tokyo, Japan) for providing the multibending ultraslim endoscope. Research support for this study was provided in part by the SoonChunHyang University Research Fund. We also thank A Ri Song, RN, Song Ah Jeong, RN, Sun Hwa Cho, RN, and the rest of the nursing staff for their support and assistance with the procedure.

• References

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Corresponding author

Publication History

Received: 01 December 2020

Accepted after revision: 05 May 2021

Article published online:
06 July 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Chan JHY, Teoh AYB. The development of peroral cholecystoscopy and advanced gallbladder interventions. Endosc Ultrasound 2018; 7: 85-88
  CrossrefPubMedSearch in Google Scholar
• 2 Jang JW, Lee SS, Park DH. et al. Feasibility and safety of EUS-guided transgastric/transduodenal gallbladder drainage with single-step placement of a modified covered self-expandable metal stent in patients unsuitable for cholecystectomy. Gastrointest Endosc 2011; 74: 176-181
  CrossrefPubMedSearch in Google Scholar
• 3 Chan SM, Teoh AYB, Yip HC. et al. Feasibility of per-oral cholecystoscopy and advanced gallbladder interventions after EUS-guided gallbladder stenting (with video). Gastrointest Endosc 2017; 85: 1225-1232
  CrossrefPubMedSearch in Google Scholar
• 4 Ge N, Sun S, Sun S. et al. Endoscopic ultrasound-assisted transmural cholecystoduodenostomy or cholecystogastrostomy as a bridge for per-oral cholecystoscopy therapy using double-flanged fully covered metal stent. BMC Gastroenterol 2016; 16: 9
  CrossrefPubMedSearch in Google Scholar
• 5 Itoi T, Itokawa F, Tsuchiya T. et al. Transgastric large gallstone extraction through a lumen-apposing metal stent in a patient with acute cholecystitis. Gastrointest Endosc 2014; 79: 547
  CrossrefPubMedSearch in Google Scholar
• 6 Teoh AY, Chan AW, Chiu PW. et al. In vivo appearances of gallbladder carcinoma under magnifying endoscopy and probe-based confocal laser endomicroscopy after endosonographic gallbladder drainage. Endoscopy 2014; 46: E13-E14
  Thieme ConnectPubMedSearch in Google Scholar
• 7 Lee YN, Moon JH, Lee TH. et al. Prospective randomized trial of a new multibending versus conventional ultra-slim endoscope for peroral cholangioscopy without device or endoscope assistance (with video). Gastrointest Endosc 2020; 91: 92-101
  CrossrefPubMedSearch in Google Scholar
• 8 Yoo HW, Moon JH, Jo SJ. et al. A novel electrocautery-enhanced delivery system for one-step endoscopic ultrasound-guided drainage of the gallbladder and bile duct using a lumen-apposing metal stent: a feasibility study. Endoscopy 2020;
  Thieme ConnectPubMedSearch in Google Scholar
• 9 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
  CrossrefPubMedSearch in Google Scholar
• 10 Inui K, Nakazawa S, Yoshino J. et al. Percutaneous cholecystoscopy. Endoscopy 1989; 21 Suppl 1: 361-364
  Thieme ConnectPubMedSearch in Google Scholar
• 11 Fujita R, Hirata N, Fujita Y. Peroral cholecystoscopy. Endoscopy 1989; 21: 378-380
  Thieme ConnectPubMedSearch in Google Scholar
• 12 Takahara N, Kawakubo K, Isayama H. et al. Cholesterolosis of the gallbladder visualized by peroral cholecystoscopy using a SpyGlass probe. Endoscopy 2012; 44: E145-E146
  Thieme ConnectPubMedSearch in Google Scholar
• 13 Gutkin E, Hussain SA, Kim SH. The successful treatment of chronic cholecystitis with SpyGlass cholangioscopy-assisted gallbladder drainage and irrigation through self-expandable metal stents. Gut Liver 2012; 6: 136-138
  CrossrefPubMedSearch in Google Scholar
• 14 Barkay O, Bucksot L, Sherman S. Endoscopic transpapillary gallbladder drainage with the SpyGlass cholangiopancreatoscopy system. Gastrointest Endosc 2009; 70: 1039-1040
  CrossrefPubMedSearch in Google Scholar
• 15 Walter D, Teoh AY, Itoi T. et al. EUS-guided gall bladder drainage with a lumen-apposing metal stent: a prospective long-term evaluation. Gut 2016; 65: 6-8
  CrossrefPubMedSearch in Google Scholar

• Supplementary Material