Safety and efficacy of endoscopic transpapillary gallbladder stenting for symptomatic gallbladder disease in cirrhosis: A systematic review and meta-analysis
Iqbal U, Haq KF, Khara HS, Shah RN, Khan MA, Siddiqui MA, Hu Y, Abu Ghanimeh MK, Sadiq O, Watson A, Salgia R, and Zuchelli T. Safety and efficacy of endoscopic transpapillary gallbladder stenting for symptomatic gallbladder disease in cirrhosis: A systematic review and meta-analysis. Gastrointestinal Endoscopy 2020; 91(6):AB380.
Background: Symptomatic gallbladder disease is common in patients with cirrhosis and cholecystectomy has been the preferred method for treatment. Nevertheless, these patients are at high risk for complications and an alternate, less invasive, approach could decrease morbidity and mortality. Endoscopic insertion of cystic duct (transpapillary gallbladder) stent has been shown to be effective in treatment of symptomatic gallbladder disease. However, evidence is limited at this time, more so in patients with underlying cirrhosis. Methods: A comprehensive literature review was conducted by searching databases including Embase, Cochrane Central and PubMed from inception to August 2019 to identify all studies that evaluated outcomes of endoscopic transpapillary gallbladder stenting (ETGS) for symptomatic gallbladder disease in patients with cirrhosis. Our primary outcome was technical success defined as successful stent placement and clinical success defined as resolution of gallbladder disease symptoms. Proportions and 95% confidence intervals (CIs) were initially calculated for each of the event outcomes. Pooled estimates and measures of variability from each included study were used to generate forest plots. Publication bias was evaluated by Egger’s test. Variability between studies was assessed by heterogeneity tests using I2 statistic. All analyses were conducted using RStudio (Version 1.0.136) using the ‘Meta’ and ‘Metafor’ package. Results: Seven studies including 109 patients met our inclusion criteria. At least, 94 patients (86%) had a Child-Turcotte-Pugh score of B or C. Most common indiciation for ETGS was recurrent biliary colic (51.3%) followed by acute cholecystitis (33.9%), and biliary pancreatitis (11.9%). ETGS was techinically successful in 104 patients with pooled technical success of 95% (95% CI: 89%-98%) with no statistical hetereogeniety as calculated by I2=0. In patients with successful ETGS, clinical success was achieved in 99 patients with pooled clinical success of 97% (95% CI: 82%-99%) with statistical heterogeniety I2=33%. Adverse events were reported in 15.6% with most common being pancreatitis (4.6%) followed by cholangitis (3.7%), and duodenal ulceration (1.8%). Technical failure resulted due to inability to cannulate the cystic duct (1.8%), impacted cystic duct stone (1.8%), and tortuous inflammed cystic duct complicated by perforation requiring cholecystostomy tube (0.9%). Overall mortality was found to be less than 1% as one patient with acute cholecystitis ultimately required open cholecystectomy complicated by sepsis and death. Conclusion: ETGS is a relatively safe and effective therapeutic modality for symptomatic gallbladder disease in patients with end-stage liver disease. Larger prospective trials are needed to better evaluate the safety and efficacy of ETGS for symptomatic gallbladder disease in patients with cirrhosis.