Clinical Endoscopy

Systematic Review and Meta-Analysis

Percutaneous cholecystolithotomy and lithotripsy for managing acute calculous cholecystitis in non-surgical candidates: a systematic review and meta-analysis: Arsalan Nadeem, Ali Husnain, Aleena Ahmed, Haider Ashfaq, Hamza Ashraf, Zain Ali Nadeem, Khawaja Abdul Rehman, Shahroze Ahmad, Muhammad Rafay Shahzad Cheema; Clin Endosc 2025;58(5):684-695. Published online August 27, 2025; DOI: https://doi.org/10.5946/ce.2024.256

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: This study aimed to review and update the evidence regarding the efficacy and safety of percutaneous cholecystolithotomy/lithotripsy (PCCL) for managing acute calculous cholecystitis (ACC) in non-surgical candidates.
Methods
A systematic search of PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase was conducted. We included studies focusing on the use of PCCL in patients deemed ineligible for surgery owing to ACC and reporting outcomes such as technical success, stone clearance, recurrence, and length of hospital stay. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Results
Meta-analysis of 13 studies showed a technical success rate of 97%, with stone and cholecystitis recurrence in 10% and 1% of cases, respectively. The pooled average length of hospital stay was 2.79 days. Complications included retained stones (3%), duct perforations (6%), catheter displacement (5%), bleeding (4%), and bile leakage (5%). A sensitivity analysis confirmed the robustness of these results.
Conclusions
PCCL demonstrated high efficacy with minimal recurrence and low complication rates in managing ACC in non-surgical candidates. Further randomized controlled trials are necessary to compare its efficacy and safety with standard care approaches, such as cholecystectomy or percutaneous cholecystostomy.

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Original Articles

The feasibility of percutaneous transhepatic gallbladder aspiration for acute cholecystitis after self-expandable metallic stent placement for malignant biliary obstruction: a 10-year retrospective analysis in a single center: Akihisa Ohno, Nao Fujimori, Toyoma Kaku, Masayuki Hijioka, Ken Kawabe, Naohiko Harada, Makoto Nakamuta, Takamasa Oono, Yoshihiro Ogawa; Clin Endosc 2022;55(6):784-792. Published online October 21, 2022; DOI: https://doi.org/10.5946/ce.2021.244

Abstract PDF PubReader ePub

Background
/Aims: Patients with acute cholecystitis (AC) after metallic stent (MS) placement for malignant biliary obstruction (MBO) have a high surgical risk. We performed percutaneous transhepatic gallbladder aspiration (PTGBA) as the first treatment for AC. We aimed to identify the risk factors for AC after MS placement and the poor response factors of PTGBA.
Methods
We enrolled 401 patients who underwent MS placement for MBO between April 2011 and March 2020. The incidence of AC was 10.7%. Of these 43 patients, 37 underwent PTGBA as the first treatment. The patients’ responses to PTGBA were divided into good and poor response groups.
Results
There were 20 patients in good response group and 17 patients in poor response group. Risk factors for cholecystitis after MS placement included cystic duct obstruction (p<0.001) and covered MS (p<0.001). Cystic duct obstruction (p=0.003) and uncovered MS (p=0.011) demonstrated significantly poor responses to PTGBA. Cystic duct obstruction is a risk factor for cholecystitis and poor response factor for PTGBA, whereas covered MS is a risk factor for cholecystitis and an uncovered MS is a poor response factor of PTGBA for cholecystitis.
Conclusions
The onset and poor response factors of AC after MS placement were different between covered and uncovered MS. PTGBA can be a viable option for AC after MS placement, especially in patients with covered MS.

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Post-endoscopic retrograde cholangiopancreatography cholecystitis: A review of incidence, risk factors, prevention, and management
Suprabhat Giri, Shivaraj Afzalpurkar, Prasanna Gore, Gaurav Khatana, Saroj Kanta Sahu, Dibya Lochan Praharaj, Bipadabhanjan Mallick, Preetam Nath, Sridhar Sundaram, Manoj Kumar Sahu
World Journal of Gastrointestinal Endoscopy.2025;[Epub] CrossRef
Endeavors to prevent stent malfunction: new insights into the risk factors for recurrent biliary obstruction
Sung-Jo Bang
Clinical Endoscopy.2024; 57(1): 56. CrossRef
Endoscopic Ultrasound-Guided Naso-gallbladder Drainage Using a Dedicated Catheter for Acute Cholecystitis After Transpapillary Metal Stent Placement for Malignant Biliary Obstruction
Tadahisa Inoue, Rena Kitano, Mayu Ibusuki, Kazumasa Sakamoto, Satoshi Kimoto, Yuji Kobayashi, Yoshio Sumida, Yukiomi Nakade, Kiyoaki Ito, Masashi Yoneda
Digestive Diseases and Sciences.2023; 68(12): 4449. CrossRef
The writing on the wall: self-expandable stents for endoscopic ultrasound-guided hepaticogastrostomy?
Hyung Ku Chon, Shayan Irani, Tae Hyeon Kim
Clinical Endoscopy.2023; 56(6): 741. CrossRef
How should a therapeutic strategy be constructed for acute cholecystitis after self-expanding metal stent placement for malignant biliary obstruction?
Mamoru Takenaka, Masatoshi Kudo
Clinical Endoscopy.2022; 55(6): 757. CrossRef

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Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis using Two Gallbladder Stents (Dual Gallbladder Stenting): Zain A Sobani, Sergio A. Sánchez-Luna, Tarun Rustagi; Clin Endosc 2021;54(6):899-902. Published online May 31, 2021; DOI: https://doi.org/10.5946/ce.2021.023

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Background
/Aims: Endoscopic transpapillary gallbladder drainage (ETPGBD) is gaining popularity for the management of acute cholecystitis (AC) in high-risk patients. However, the stents placed during the procedure are not immune to obstruction. Here we describe a novel technique of stenting with two transpapillary stents and evaluate its technical feasibility, safety, and efficacy in AC.
Methods
A retrospective analysis of all patients undergoing ETPGBD using dual stents for AC at our institution between November 1, 2017 and August 31, 2020 was conducted. We abstracted patient data to evaluate technical and clinical success, adverse events, and long-term outcomes. Two stents were placed either during the index procedure or during an interval procedure performed 4–6 weeks after the index procedure.
Results
A total of 21 patients underwent ETPGBD with dual stenting (57.14% male, mean age: 62.14±17.21 years). The median interval between the placement of the first and the second stents was 37 days (range: 0–226 days). Technical and clinical success rates were 100%, with a recurrence rate of 4.76% (n=1) and adverse event rate of 9.52% (n=2) during a mean follow-up period of 471.74±345.64 days (median: 341 days, range: 55–1084 days).
Conclusions
ETPGBD with dual gallbladder stenting is a safe and effective technique for long-term gallbladder drainage in non-surgical candidates. Larger controlled studies are needed to validate our findings for the widespread implementation of this technique.

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Nicole Cherng, Ikechukwu Achebe, Mason Winkie, Julie Thomann, Eric Then, Neil B. Marya
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Reviews

Practical Approaches for High-Risk Surgical Patients with Acute Cholecystitis: The Percutaneous Approach versus Endoscopic Alternatives: Rungsun Rerknimitr, Khanh Cong Pham; Clin Endosc 2020;53(6):678-685. Published online January 9, 2020; DOI: https://doi.org/10.5946/ce.2019.186

Abstract PDF PubReader ePub

In high-risk surgical patients with acute cholecystitis who are not candidates for early laparoscopic cholecystectomy, gallbladder (GB) drainage is an alternative treatment option. Percutaneous transhepatic gallbladder drainage (PTGBD) is a recommended first line intervention because of its high efficacy and feasibility in most centers. However, with the advent of endoscopic accessories and technology, endoscopic GB drainage has been chosen as a more favorable choice by endoscopists. Endoscopic transpapillary gallbladder drainage (ETGBD) can be performed under either fluoroscopic or peroral cholangioscopic guidance via endoscopic retrograde cholangiopancreatography by the transpapillary placement of a long double-pigtail stent. In a patient with common bile duct stones, this procedure is accompanied with stone removal. ETGBD is especially useful for acute cholecystitis patients who are contraindicated for PTGBD or those with severe coagulopathy, thrombocytopenia, and abnormal anatomy. Moreover, the advantage of ETGBD is its preservation of the external GB structure. Thereby it would not disturb the future cholecystectomy. Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic, fully covered metallic, or lumen-apposing metal stents transmurally has emerged as a modality for GB drainage with higher technical and clinical success rates. EUS-GBD can provide a more permanent GB drainage than PTGBD and ETGBD.

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Current Status in the Treatment of Acute Cholecystitis Patients Receiving Antithrombotic Therapy: Is Endoscopic Drainage Feasible?- A Systematic Review: Ryota Sagami, Kenji Hayasaka, Hidefumi Nishikiori, Hideaki Harada, Yuji Amano; Clin Endosc 2020;53(2):176-188. Published online January 9, 2020; DOI: https://doi.org/10.5946/ce.2019.177

Abstract PDF PubReader ePub

The bleeding complication risk of surgery or percutaneous transhepatic gallbladder drainage (PTGBD) may increase in patients with acute cholecystitis receiving antithrombotic therapy (ATT). Endoscopic gallbladder drainage (EGBD) may be recommended for such patients. English articles published between 1991 and 2018 in peer-reviewed journals that discuss cholecystectomy, PTGBD, and EGBD in patients with ATT or coagulopathy were reviewed to assess the safety of the procedures, especially in terms of the bleeding complication. There were 8 studies on cholecystectomy, 3 on PTGBD, and 1 on endoscopic transpapillary gallbladder drainage (ETGBD) in patients receiving ATT. With respect to EGBD, 28 studies on ETGBD (including 1 study already mentioned above) and 26 studies on endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) were also analyzed. The overall bleeding complication rate in patients with ATT who underwent cholecystectomy was significantly higher than that in patients without ATT (6.5% [23/354] vs. 1.2% [26/2,224], p<0.001). However, the bleeding risk of cholecystectomy and PTGBD in patients receiving ATT was controversial. The overall technical success, clinical success, and bleeding complication rates of ETGBD vs. EUS-GBD were 84% vs. 96% (p<0.001), 92% vs. 97% (p<0.001), and 0.65% vs. 2.1% (p=0.005), respectively. One patient treated with ETGBD experienced bleeding complication among 191 patients with bleeding tendency. ETGBD may be an ideal drainage procedure for patients receiving ATT from the viewpoint of bleeding, although EUS-GBD is also efficacious.

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Original Articles

A New Technique of Endoscopic Transpapillary Gallbladder Drainage Combined with Intraductal Ultrasonography for the Treatment of Acute Cholecystitis: Ryota Sagami, Kenji Hayasaka, Tetsuro Ujihara, Ryotaro Nakahara, Daisuke Murakami, Tomoyuki Iwaki, Satoshi Suehiro, Yasushi Katsuyama, Hideaki Harada, Yuji Amano; Clin Endosc 2020;53(2):221-229. Published online November 5, 2019; DOI: https://doi.org/10.5946/ce.2019.099

Abstract PDF PubReader ePub

Background
/Aims: Endoscopic transpapillary gallbladder drainage (ETGBD) is useful for the treatment of acute cholecystitis; however, the technique is difficult to perform. When intraductal ultrasonography (IDUS) is combined with ETGBD, the orifice of the cystic duct in the common bile duct may be more easily detected in the cannulation procedure. The aim of this study was to evaluate the efficacy of ETGBD with IDUS compared with that of ETGBD alone.
Methods
A total of 100 consecutive patients with acute cholecystitis requiring ETGBD were retrospectively recruited. The first 50 consecutive patients were treated using ETGBD without IDUS, and the next 50 patients were treated using ETGBD with IDUS. Through propensity score matching analysis, we compared the clinical outcomes between the groups. The primary outcome was the technical success rate.
Results
The technical success rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (92.0% vs. 76.0%, p=0.044). There was no significant difference in procedure length between the two groups (74.0 min vs. 66.7 min, p=0.310). The complication rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (6.0% vs. 0%, p<0.001); however, only one case showed an IDUS technique-related complication (pancreatitis).
Conclusions
The assistance of IDUS may be useful in ETGBD.

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Endoscopic Ultrasonography-Guided Gallbladder Drainage as a Treatment Option for Acute Cholecystitis after Metal Stent Placement in Malignant Biliary Strictures: Fumisato Kozakai, Yoshihide Kanno, Kei Ito, Shinsuke Koshita, Takahisa Ogawa, Hiroaki Kusunose, Kaori Masu, Toshitaka Sakai, Toji Murabayashi, Keisuke Yonamine, Yujiro Kawakami, Yuki Fujii, Kazuaki Miyamoto, Yutaka Noda; Clin Endosc 2019;52(3):262-268. Published online March 15, 2019; DOI: https://doi.org/10.5946/ce.2018.183

Abstract PDF PubReader ePub

Background
/Aims: It is often difficult to manage acute cholecystitis after metal stent (MS) placement in unresectable malignant biliary strictures. The aim of this study was to evaluate the feasibility of endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) for acute cholecystitis.
Methods
The clinical outcomes of 10 patients who underwent EUS-GBD for acute cholecystitis after MS placement between January 2011 and August 2018 were retrospectively evaluated. The procedural outcomes of percutaneous transhepatic gallbladder drainage (PTGBD) with tube placement (n=11 cases) and aspiration (PTGBA) (n=27 cases) during the study period were evaluated as a reference.
Results
The technical success and clinical effectiveness rates of EUS-GBD were 90% (9/10) and 89% (8/9), respectively. Severe bile leakage that required surgical treatment occurred in one case. Acute cholecystitis recurred after stent dislocation in 38% (3/8) of the cases. Both PTGBD and PTGBA were technically successful in all cases without severe adverse events and clinically effective in 91% and 63% of the cases, respectively.
Conclusions
EUS-GBD after MS placement was a feasible option for treating acute cholecystitis. However, it was a rescue technique following the established percutaneous intervention in the current setting because of the immature technical methodology, including dedicated devices, which need further development.

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Review

Endoscopic Ultrasound-Guided Gallbladder Drainage Using a Lumen-Apposing Metal Stent for Acute Cholecystitis: A Systematic Review: Deepanshu Jain, Bharat Singh Bhandari, Nikhil Agrawal, Shashideep Singhal; Clin Endosc 2018;51(5):450-462. Published online June 1, 2018; DOI: https://doi.org/10.5946/ce.2018.024

Abstract PDF PubReader ePub

Surgery remains the standard treatment for acute cholecystitis except in high-risk candidates where percutaneous transhepatic gallbladder drainage (PT-GBD), endoscopic transpapillary cystic duct stenting (ET-CDS), and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) are potential choices. PT-GBD is contraindicated in patients with coagulopathy or ascites and is not preferred by patients owing to aesthetic reasons. ET-CDS is successful only if the cystic duct can be visualized and cannulated. For 189 patients who underwent EUS-GBD via insertion of a lumen-apposing metal stent (LAMS), the composite technical success rate was 95.2%, which increased to 96.8% when LAMS was combined with co-axial self-expandable metal stent (SEMS). The composite clinical success rate was 96.7%. We observed a small risk of recurrent cholecystitis (5.1%), gastrointestinal bleeding (2.6%) and stent migration (1.1%). Cautery enhanced LAMS significantly decreases the stent deployment time compared to non-cautery enhanced LAMS. Prophylactic placement of a pigtail stent or SEMS through the LAMS avoids re-interventions, particularly in patients, where it is intended to remain in situ indefinitely. Limited evidence suggests that the efficacy of EUS-GBD via LAMS is comparable to that of PT-GBD with the former showing better results in postoperative pain, length of hospitalization, and need for antibiotics. EUS-GBD via LAMS is a safe and efficacious option when performed by experts.

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Recent advances in management of acalculous cholecystitis
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A Case of Acute Cholecystitis with a Perforation Complicating Endoscopic Retrograde Cholangiopancreatography: Seung Hee Ryu, M.D., Myung Hwan Noh, M.D., Ji Sun Han, M.D., Su Mi Woo, M.D., Byung Geun Kim, M.D., Chien Ter Hsing, M.D., So Young Park, M.D. and Joon Mo Kim, M.D.; Korean J Gastrointest Endosc 2011;42(3):185-189. Published online March 28, 2011

Abstract PDF: The incidence of acute cholecystitis complicating endoscopic retrograde Cholangiopancreatography (ERCP) is rarely reported at 0.2% but is usually associated with a cystic duct obstruction caused by gallstones, gallbladder polyps, or cancer. However, acute cholecystitis with a gallbladder perforation after ERCP without a history of cystic duct obstruction can develop very rarely and has not yet been reported in Korea. We report a case of acute cholecystitis with gallbladder perforation and aggravation of a pancreatic pseudocyst after diagnostic ERCP in a man with a pancreatic cystic lesion. He has been successfully cured using only percutaneous transhepatic gallbladder drainage and antibiotics with no surgery. (Korean J Gastrointest Endosc 2011;42:185-189)

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Percutaneous Transhepatic Gallbladder Stenting for Acute Cholecystitis after Palliative Metallic Biliary Stenting: Hwal Suk Cho, M.D., Sun Mi Lee, M.D., Chan Won Park, M.D., Ji Young Kim, M.D., Do Hoon Kim, M.D., Kee Tae Park, M.D., Tae Oh Kim, M.D., Jeong Heo, M.D., Gwang Ha Kim, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2006;33(5):322-325. Published online November 30, 2006

Abstract PDF: Metallic biliary stenting to relieve a malignant biliary obstruction can cause a cystic duct obstruction and acute cholecystitis. Percutaneous transhepatic cholecystostomy is often performed in patients with a limited life expectancy but can have a significant impact on the quality of life. Percutaneous transhepatic gallbladder stenting (PTGS) was performed across the cystic duct via the cholecystostomy tube tract to allow the removal of the cholecystostomy tube. The patient remained asymptomatic for 7 months after PTGS. In conclusion, PTGS across the cystic duct may be considered a treatment option in selected patients who develop acute cholecystitis after palliative metallic biliary stenting. (Korean J Gastrointest Endosc 2006;33: 322⁣325)

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The Roles of Endoscopic Sphincterotomy and Cholecystectomy in Acute Biliary Pancreatitis: Ji Bong Jeong, M.D.*, Ji Kon Ryu, M.D., Joo Kyung Park, M.D., Won Jae Yoon, M.D., Sang Hyub Lee, M.D., Jin-Hyeok Hwang, M.D.^†, Jun Kyu Lee, M.D.^‡, Yong-Tae Kim, M.D. and Yong Bum Yoon, M.D.; Korean J Gastrointest Endosc 2006;33(3):152-158. Published online September 30, 2006

Abstract PDF: Background
/Aims: Stone removal can prevent recurrence of acute biliary pancreatitis. This study examined the natural course of acute biliary pancreatitis and compared the results obtained using endoscopic sphincterotomy (EST) and cholecystectomy. In addition, the incidence and risk factors associated with acute cholecystitis were estimated when a cholecystectomy had not been performed. Methods: The medical records of 113 patients diagnosed with acute biliary pancreatitis in Seoul National University Hospital from January 1990 to April 2005 were reviewed retrospectively. Results: Twenty-five patients received no specific treatment of which 15 (60.0%) experienced a recurrence during a mean follow-up period of 36.0 months. Fifty-two patients received EST only and did not experience a recurrence during a mean follow-up of 29.8 months. Thirty-six patients underwent a cholecystectomy, and 1 (2.8%) patient experienced a second attack during a follow-up of 35.2 months. The clinical factors predictive of pancreatitis recurrence in patients without treatment could not be identified. Acute cholecystitis developed in 7 out of 77 (9.1%) patients who did not receive a cholecystectomy during a mean follow-up period of 33.3 months, and patients with both gallbladdor and common bile duct stones were found to be more prone to a recurrence. Conclusions: Sixty percent of patients with acute biliary pancreatitis without treatment experienced a second attack, which could be prevented by EST. A cholecystectomy is not always necessary as a routine treatment after EST for preventing pancreatitis, and is recommended for patients with both visible gallbladdor and common bile duct stones at the time of the first attack. (Korean J Gastrointest Endosc 2006;33:152⁣158)

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A Case of Acute Acalculous Cholecystitis Complicating Endoscopic Retrograde Cholangiopancreatography: Byeong Kab Yoon, M.D., In Suh Park, M.D.*, Yong Sun Jeon, M.D.†, Jin-Woo Lee, M.D., Seok Jeong, M.D., Jung Il Lee, M.D., Kye Sook Kwon, M.D., Don Haeng Lee, M.D., Pum-Soo Kim, M.D., Hyung Gil Kim, M.D., Yong Woon Shin, M.D. and Young Soo Kim, M.D.; Korean J Gastrointest Endosc 2005;31(1):62-67. Published online July 30, 2005

Abstract PDF: Endoscopic retrograde cholangiopancreatography (ERCP) has gained wide acceptance as a valuable tool for the diagnosis and management of disease of the pancreas and biliary tract. Complications associated with ERCP include bleeding, perforation, pancreatitis, and cholangitis, and the incidence is about 5∼10%. Acute acalculous cholecystitis can be developed rarely after ERCP. It tends to have more complicated course, resulting in higher morbidity and mortality. We report a case of acute acalculous cholecystitis complicating therapeutic ERCP in a 52-year-old man with primary common bile duct stone. He underwent open cholecystectomy because of uncontrolled infection and rapid progression to septic shock. Although acute acalculous cholecystitis is one of rare complications developed after ERCP, it should be considered as one of the differential diagnosis in patients who complain of abdominal pain after ERCP because of high mortality rate and the need for prompt surgical management. (Korean J Gastrointest Endosc 2005;31:62⁣67)

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수술 고위험군 급성 담낭염 환자에서의 경피경간적 담낭경검사의 안전성과 유용성 ( Safety and Usefulness of Percutaneous Transhepatic Cholecystoscopy (PTCCS) in High-Risk Surgical Patients Manifesting Acute Cholecystitis ): Korean J Gastrointest Endosc 2001;22(1):27-31. Published online November 30, 2000

Abstract PDF: Background
/Aims: The aim of the present study is to identify the diagnostic and therapeutic usefulness of percutaneous transhepatic cholecystoscopic examination (PTCCS) in high-risk surgical patients manifesting acute cholecystitis. Methods: Between January 1992 and June 1998, 33 consecutive patients who underwent percutaneous transhepatic cholecystostomy (PC) and subsequent PTCCS for the management of acute cholecystitis were included. Results: PC and subsequent PTCCS were successfully accomplished in all of 33 patients. During PTCCS, minor complication (2 of minor bleeding during electrohydraulic lithotripsy, 2 of tube dislodgement and 1 of bile leakage to peritoneum) occurred in five patients. PTCCS revealed 26 cases of gallstones, 3 cases of sludge ball, 3 cases of gallbladder carcinoma and 1 case of clonorchiasis related with acute cholecystitis. Three cases of the gallbladder cancers which were not predicted radiologically were incidentally found during PTCCS. For 26 patients with gallstones, PTCCS and concomitant stone removal were successfully carried out in one to four consecutive sessions (mean 2.2 sessions). Gallstones recurred in three (3/22, 14%) patients during the mean follow-up period of 27 months. All of them remain asymptomatic. Conclusions: PTCCS may be justified in the management of acute cholecystitis in selected patients with high surgical risk. (Korean J Gastrointest Endosc 2001;22:27 - 31)

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