Naoyuki Toyota, Tadahiro Takada, Hodaka Amano, Masahiro Yoshida, Fumihiko Miura, and Keita Wada

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1 J Hepatobiliary Pancreat Surg (2006) 13:80 85 DOI /s Endoscopic naso-gallbladder drainage in the treatment of acute cholecystitis: alleviates inflammation and fixes operator s aim during early laparoscopic cholecystectomy Naoyuki Toyota, Tadahiro Takada, Hodaka Amano, Masahiro Yoshida, Fumihiko Miura, and Keita Wada Department of Surgery, Teikyo University School of Medicine, Kaga-cho, Itabashi-ku, Tokyo , Japan Abstract In 1984, Kozarek first reported the use of endoscopic retrograde cholangiopancreatography (ERCP) to perform selective cannulation of the cystic duct, and since then this procedure has also been reported by others. With this procedure, disorders in the gallbladder can be examined in detail, using, for example, selective cytology, and drainage for acute cholecytitis can also be performed. With this procedure, we were able to successfully perform early laparoscopic cholecystectomy (LC). Although surgery is often problematic in patients with acute cholecystitis because of inflammation, making Callot s triangle difficult to distinguish, the use of endoscopic naso-gallbladder drainage (ENGBD) during surgery enables us to identify the cystic duct for catheter cannulation. We performed early LC for acute cholecystitis in 18 of 22 patients, while 18 other patients underwent open cholecystectomy during the same period (retrospective study). These two groups were then compared. The LC group had shorter pre- and postoperative periods and shorter hospitalization (P < 0.05). ENGBD resulted in very little bleeding. None of the ENGBD patients required conversion to open surgery, whereas 11.1% of the non-engbd patients were converted. ENGBD was successfully employed in 18 of the initial 22 (81.8%) patients. The favorable points in using ENGBD with LC were that (i) the gallbladder inflammation was alleviated even if patients had ascites, and (ii) use of ENGBD normally improved visualization and made cystic duct identification easier. However, if ERCP cannot be carried out, the performance of ENGBD must also be ruled out. Key words Acute cholecystitis ERCP Cystic duct cannulation ENGBD Endoscopic transpapillary gallbladder drainage Callot s triangle Offprint request to: N. Toyota Received: October 19, 2005 / Accepted: October 30, 2005 Introduction Laparoscopic cholecystectomy (LC) is increasingly being used for the surgical treatment of gallbladder stones, but this approach is not always without complications. In particular, when treating acute cholecystitis, in comparison to non-inflammatory conditions, surgical difficulty can be increased by excessive bleeding and a poorly visualized operative field, often resulting in conversion to open surgery. Another problem concerns difficulty in anatomically determining the cystic duct, as acute cholecystitis often shows a pattern of chronic inflammation frequently interrupted by episodes of severe inflammation, raising the severity of the chronic inflammatory level. This makes definite identification of the anatomical relationship of the area to be extirpated very difficult. In addition, during the performance of LC on the cystic duct and Callot s triangle in the treatment of acute cholecystitis, great care must be taken so as not to cause damage to the cystic and hepatic arteries, bile ducts, and other organs. We consider that the exact anatomical location of Callot s triangle, and especially identification of the cystic duct, would enable us to safely perform LC for earlystage acute cholecystitis. Preoperatively, therefore, utilizing an endoscopic retrograde cholangiopancreatography (ERCP) technique, the installation of a catheter into the gallbladder via the transpapillary route for the performance of endoscopic nasogallbladder drainage (ENGBD), would result in alleviation of the acute inflammation due to a reduction in internal pressure. The resulting increased possibility of cystic duct identification during the LC procedure indicates that the performance of safe, early LC can be expected. In this article, we would like to emphasize the advantages of the use of ENGBD with LC.

2 N. Toyota et al.: Endoscopic naso-gallbladder drainage 81 Subjects Between January 1, 2004, and January 1, 2005, we experienced 36 patients with acute cholecystitis at the Division of Hepatopancreatobiliary Surgery, Department of Surgery, Teikyo University School of Medicine. Twenty-two of the hospitalized patients were treated with ENGBD. The procedure was unsuccessful in 4 (non-engbd), so, finally, 18 ENGBD patients were used for a comparative study. The other 18 patients (non-engbd) consisted of the 4 patients with unsuccessful ENGBD, plus 14 patients for whom an ENGBD operator was not available (retrospective study). a gallstone (Fig. 3). However, after several attempts, in such an instance, the guidewire suddenly entered the gallbladder cavity (Fig. 4). A Flexima 5- or 6-Fr nasobiliary catheter (Boston Scientific) was then inserted to aspirate the contents of the gallbladder (Fig. 5). In many patients, initial aspiration produced bile mixed with pus, with subsequent biliary secretions similar to those in normal ENGBD. The patients symptoms of high fever and abdominal pain resolved followed aspiration of the infected bile. Preoperative examination and other laboratory studies were then conducted, and, 1 or 2 days after the ERCP, the patients underwent LC. Methods Methodology of ENGBD The instruments necessary for ENGBD and the ENGBD procedure are described below, under Results. Use of ENGBD with LC The use of ENGBD with LC is also described under Results. Examination and comparison of ENGBD and non-engbd patients Data were statistically analyzed by t-test, and a P value of less than 0.05 was considered significant. Results Instruments necessary for ENGBD As depicted in Fig. 1, the following instruments were used for the ENGBD procedure: a radiofocus Jagwire guidewire (400 cm, angle type) (Fig. 1A), a guiding Contour catheter (Fig. 1B), and a Flexima 5- or 6-Fr nasobilitary catheter (Fig. 1C) (all from Boston Scientific, Natick, MA, USA); and a special-purpose Haber ramp catheter (Wilson-Cook, Winston Salem, NC, USA) (Fig. 1D). ENGBD procedure ENGBD was performed in the manner of endoscopic naso-biliary drainage (ENBD). First, following ERCP, the ERCP catheter was inserted further through a bile duct to achieve deep cannulation into the cystic duct (Fig. 2). The radiofocus guidewire was then also inserted and directed toward the cystic duct, but, in some instances, it was blocked by a hard object, assumed to be Use of ENGBD with LC The application of ENGBD for the LC procedure in the treatment of acute cholecystitis has two advantages, one being that the intraoperative cholangiography can be performed at any time, and the other that the cystic duct can be distinguished and even contacted. Because of the severe inflammation accompanying acute cholecystitis, the cystic duct is difficult to identify, but, with ENGBD, its restiform shape is easily visualized, it can be seized with forceps, and it can be clearly differentiated from the common bile duct. In addition, because of the distinct color of the ENGBD tube, this tube is easily identified when incising the cystic tube. The surgery performed was LC. In a typical patient, pronounced perioperative inflammatory adhesions were noted around the gallbladder, but it was possible to reach into the gallbladder with forceps after the contents of the gallbladder had been aspirated using ENGBD. By inserting the catheter further into the gallbladder, we were also able to clearly identify the cystic duct. After the cystic duct had been partially opened to verify the presence of the catheter (Fig. 6a, b), the ENGBD catheter was withdrawn, and the cystic duct was closed by ordinary methods, using a clip. The gallbladder was subsequently removed by standard LC. Examination and comparison of ENGBD and non-engbd patients Background The characteristics of the ENGBD and non-engbd patients (number of patients, age, sex, body mass index [BMI, kg/m 2 ]) are shown in Table 1. Hospitalization, pre- and post-lc intervals, bleeding, and rate of conversion to open surgery The interval between hospitalization and the initiation of ENGBD was 0.25 ± 0.52 days. As for the pre-lc interval, that of the ENGBD patients was 1.9 ± 1.3 days, and that of the non-engbd patients was 3.1 ± 1.6 days,

3 82 N. Toyota et al.: Endoscopic naso-gallbladder drainage A B C Fig. 1A D. Instruments for endoscopic naso-gallbladder drainage (ENGBD). A Jagwire (Boston Scientific). B Guiding catheter: Contour (Boston Scientific). C Drainage tube (Boston Scientific). D Haber ramp catheter (Wilson-Cook) D Fig. 2. Endoscopic retrograde cholangiopancreatography (ERCP) catheter was inserted into the cystic duct, but the gallbladder was not visualized because of a stone impacted in the neck of the gallbladder

4 N. Toyota et al.: Endoscopic naso-gallbladder drainage 83 Fig. 3. Through the ERCP catheter, a radiofocus guidewire was passed beyond the obstruction Fig. 4. The radiofocus guidewire was inserted into the gallbladder Fig. 5. The ENGBD tube was inserted into the gallbladder for drainage

5 84 N. Toyota et al.: Endoscopic naso-gallbladder drainage a b Fig. 6. a The ENGBD tube was inserted further into the gallbladder, enabling the cystic duct to be easily identified (after a small incision was made into the side wall of the cystic duct) (white arrow). The ENGBD tube was identified (red arrow). b When the cystic duct (white arrow) was cut away, the ENGBD tube (red arrow) was exposed Table 1. Comparison of ENGBD and non-engbd patients ENGBD non-engbd n n = 18 n = 18 Sex F, 8; M, 10 F, 10; M, 8 Age (years) 52.5 ± ± 11.8 BMI (kg/m 2 ) 23 ± ± 3.6 Hospitalization to ENGBD (days) 0.25 ± 0.52 Pre-LC interval (days) 1.9 ± ± 1.6 P < 0.05 Post-LC interval (days) 5.1 ± ± 3.9 P < 0.05 Total hospitalization (days) 6.5 ± ± 5.2 P < 0.05 LC duration (min) 108 ± ± 42.9 Blood loss during LC (ml) Minimal 135 ± 87.8 Conversion to open surgery (%) 0% (0/18) 11.1% (2/18) ENGBD, endoscopic naso-gallbladder drainage a significant difference (P < 0.05). The post-lc intervals were 5.1 ± 1.4 days and 6.6 ± 3.9 days for ENGBD and non-engbd patients, respectively (P < 0.05). The total hospitalization were 6.5 ± 2.1 days (ENGBD) and 9.7 ± 5.2 days (non-engbd) (P < 0.05). The duration of LC, although somewhat longer in the non-engbd group, did not differ significantly between the groups. As bleeding during surgery was minimal in the ENGBD patients, a comparison was not done between the two groups. Two of the 18 non-engbd patients were converted to open surgery, whereas none of the 18 ENGBD patients required this conversion (Table 1). ENGBD was successfully performed in 18 (81.8%) of the initial 22 ENGBD patients. Discussion Cholecystectomy is the basic treatment for acute cholecystitis. However, the requirements are a medical staff with a high technical skill level, the availability of a sufficient number of surgeons for this emergency procedure, and a well-equipped facility, among others. Besides the surgical risk for certain patients, it is not infrequent that the facility itself is not able to cope with such an emergency operation. In such a case, one suitable method is gallbladder drainage, by which the affected contents can be aspirated, usually resulting in improvement of the inflammation status of the gallbladder. However, if, for some reason, this approach is not feasible, the patient must be handed over to specialists for adequate treatment. Gallbladder drainage can be carried out either by a percutaneous transhepatic approach or by an endoscopic approach. With the percutaneous approach, the drainage tube is either left in place according to a percutaneous transhepatic gallbladder drainage (PTGBD) method, 1,2 or it is inserted into the gallbladder via the transhepatic route for percutaneous transhepatic gallbladder aspiration (PTGBA). 3 PTGBD is easy to implement and has a fairly high rate of alleviating inflammation, but problems of bleeding and tube devia-

6 N. Toyota et al.: Endoscopic naso-gallbladder drainage 85 tion exist. Furthermore, although most patients with acute cholecystitis require emergency drainage, those taking anticoagulants or suffering from a severe level of inflammation accompanied by disseminated intravascular coagulation (DIC), as well as those with ascites, do not qualify for PTGBD. With the use of ENGBD, the possibility of bleeding can be ruled out. In addition, even if certain deviations of the tube occur, this would not pose a major problem. Nonetheless, ENGBD is not an easy technique, and extensive experience with the ERCP procedure is a definite prerequisite. ENGBD, in comparison to PTGBD, has a number of advantages. The afore-mentioned surgical risk patients are eligible for ENGBD. In addition, during LC, the cystic duct and its orientation are distinctly discernible anatomically, greatly increasing the safety and success of the operation. A nationwide survey done by the Japan Society for Endoscopic Surgery in 2004 found that, in the 14 years between 1990 and 2003, LC procedures were carried out. Bile duct injury occurred in 1468 patients (0.68%) and injury to other organs was seen in 667 (0.31%). These injuries may have been related to the advanced degree of inflammation or delayed timing of the operation. Of these 2135 patients, 9.64% were converted to open surgery because of complications in the affected areas, and 68.5% of the conversions were caused by the unclear anatomical relationship of the cystic duct and common bile duct. In our 18 patients treated with LC and ENGBD, although the patient population was small, complications did not arise and conversion was never deemed necessary. As for the history of ENGBD, it was first performed by Kozarek, in 1984, 4 and then by Foester and colleagues, in 1988, 5 to allow detailed inspection of the gallbladder. Use of this procedure in the treatment of acute cholecystitis was subsequently reported by Tamada et al. in 1991; 6 Feretis et al. 7 and Frederick and Garry, in 1993; 8 and Nakatsu et al., in As these few reports indicate, ENGBD is rarely performed, and it is generally initiated in order to alleviate inflammation. We have seen no prior reports of ENGBD used to perform acute cholecystitis surgery for the relief of acute inflammation with follow-up use of the ENGBD catheter to fix the operator s aim in LC. Our results indicate that this procedure can be successfully applied to provide early, safe, and minimally invasive surgery. We believe that this report will be the first of many for this application. Difficulties are frequently encountered when performing LC in patients with acute cholecystitis because it can be difficult to anatomically distinguish inflammatory adhesions within Callot s triangle, making identification of the cystic duct problematic, and raising the risk of biliary or vascular injury. However, by using the ENGBD catheter to fix the operator s aim, the cystic duct can be easily distinguished, and minimally invasive surgery can be performed safely. References 1. Sugiyama M, Tokuhara M, Atomi Y, et al. Percutaneous cholecystectomy: the optimal treatment for acute cholecystitis in the very elderly? World J Surg 1998;22: Akhan O, Akinci D, Ozmen MN, et al. Percutaneous cholecystectomy. Eur J Radiol 2002;43: Ito K, Fujita N, Noda Y, et al. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial. AJR Am J Roentgenol 2004;183: Kozarek RA. Selective cannulation of the cystic duct at the time of ERCP. J Clin Gastroenterol 1984;6: Foester EC, Auth J, Runge U, et al. Endoscopic retrograde catheterization of the gallbladder. Endoscopy 1988;20: Tamada K, Seki H, Sato K, et al. Efficacy of endoscopic retrograde cholecystoendoprosthesis (ERCCE) for cholecystitis. Endoscopy 1991;23: Feretis C, Apostolidis N, Mallas E, et al. Endoscopic drainage of acute obstructive cholecystitis in patients with increased operative risk. Endoscopy 1993;25: Frederick DJ, Garry AN. Drainage of gallbladder in patients with acute acalculous cholecystitis by transpapillary endoscopic cholecystostomy. Gastrointest Endosc 1993;39: Nakatsu T, Okada H, Saito O, et al. Endoscopic transpapillary gallbladder drainage (ETGBD) for the treatment of acute cholecystitis. J Hepatobiliary Pancreat Surg 1997;4:31 5.

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