Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis when surgery is not an option

Evidence-based recommendations on endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis when surgery is not an option. This involves inserting a stent through an endoscope into the gallbladder.

# Recommendations
Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis can be used when surgery is not an option, if standard arrangements are in place for clinical governance, consent and audit. Find out what standard arrangements mean on the NICE interventional procedures guidance page.
For auditing the outcomes of this procedure, the main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
This technically challenging procedure should only be done in specialist centres by clinicians trained and experienced in using this procedure for gallbladder drainage.
Why the committee made these recommendations
Standard treatment for acute cholecystitis is keyhole (laparoscopic) or open surgery to remove the gallbladder (cholecystectomy). But for some people, surgery is too risky, or they may not be able to have it because they have other conditions that make surgery unsuitable.
There is good evidence to show that this procedure is effective in treating acute cholecystitis and is an alternative when surgery is not an option. A disadvantage of this procedure, when compared with cholecystectomy, is that cholecystitis may reoccur.# The condition, current treatments and procedure

# The condition
Acute cholecystitis is inflammation of the gallbladder. The most common cause of acute cholecystitis is gallstones (calculous cholecystitis) blocking the duct that drains the gallbladder (cystic duct). This means bile cannot drain from the gallbladder, causing pain, nausea, vomiting and fever.
Acalculous cholecystitis is a less common, but usually more serious, cause of acute cholecystitis. It usually develops as a complication of a serious illness, infection or injury that damages the gallbladder. It can be caused by accidental damage to the gallbladder during major surgery, serious injuries or burns, sepsis, severe malnutrition, or HIV or AIDS.

# Current treatments
Initial treatment usually involves fasting, pain relief, and antibiotics if there is an infection. The gallbladder can be surgically removed (open or laparoscopic cholecystectomy) to prevent acute cholecystitis re-occurring, and to reduce the risk of developing complications, such as gangrenous cholecystitis and peritonitis.
People who cannot have surgery may be able to have percutaneous cholecystostomy. This involves inserting a drainage catheter in the gallbladder through a small entry hole made in the abdominal wall. Endoscopic transpapillary gallbladder drainage is a less common alternative. It involves inserting a plastic stent through the ampulla and cystic duct into the gallbladder endoscopically.

# The procedure
Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis is typically done under sedation or general anaesthesia using a specialist endoscope with an ultrasound probe and fluoroscopic guidance. Imaging is used before the procedure to determine its feasibility. An anastomotic tract is created into the gallbladder through either the wall of the antrum of the stomach (cholecystogastrostomy) or the wall of the duodenum (cholecystoduodenostomy). A stent is inserted to establish biliary drainage into the gut and relieve the gallbladder obstruction. Occasionally, the anastomotic tract may be created between the gallbladder and jejunum (cholecystojejunostomy) if the anatomy has been altered by previous surgery.
Different technologies are used to create the anastomotic tract and deploy the stent, and stents can be made of different materials. Single-step devices allow for single-step delivery of the stent without the need to change instruments for track dilation. Multistep devices need track dilation with a cystotome and a biliary balloon.
The aim is to drain bile from the gallbladder and avoid the need for emergency cholecystectomy, particularly in people for whom surgery poses a high risk.