Endoscopic Transpapillary Gallbladder Drainage With Two Stents Reduces the Need for Re-Intervention Compared to Single Stent

Introduction: Endoscopic transpapillary gallbladder drainage (ETPGBD) is an option for the management of gallstone-related gallbladder disease in patients who are not surgical candidates. However, guidance on the approach and follow up of these stents has not been established. Some providers elect to intermittently exchange stents while others leave them in place indefinitely. It also remains unclear whether placement of 2 gallbladder stents is superior to a single stent given the theoretical reduction in the risk of obstruction and recurrence of symptoms. This multi-center study aimed to determine whether there was a decreased need for unplanned reintervention in patients who underwent placement of 2 gallbladder stents compared to one stent. Methods: This multi-center retrospective cohort study included patients across 4 academic centers who underwent ETPGBD between June 2013 and October 2022. Patient characteristics were compared using chi-square (χ2) for categorical variables and Student t-test for continuous ones. Factors associated with placement of 2 stents were assessed using logistic regression model. The need for unplanned reintervention and adverse events were also compared using logistic regression and χ2. Two-sided P< 0.05 was considered statistically significant. Results: Seventy-six patients underwent ETPGBD with a mean follow-up duration of 811+/-1028 days. Technical and clinical success rates were 88.2% and 81.3%, respectively. The need for unplanned reintervention was significantly lower in the 2 stent group (0% vs 21.6%, P=0.04). Initial use of a 7 Fr stent was associated with placement of 2 stents (OR: 16; 95% CI: 2-129; P=0.009). The presence of a cholecystostomy tube was also associated with placement of 2 stents (OR: 11; 95% CI: 2.9-42; P< 0.001). There was no significant difference in adverse events between the 2 groups (OR: 1.1; 95% CI: 0.11-10.3; P=0.95). Conclusion: ETPGBD is a safe and effective therapy in patients with gallstone-related gallbladder disease deemed to be poor operative candidates. The use of a single transpapillary gallbladder stent is associated with a higher need for unplanned reintervention. The use of 7 Fr stents and prior cholecystostomy tube may be associated with ability to place a second stent. Endoscopists should consider planned exchange of single transpapillary gallbladder stents or interval ERCP for re-attempt at placement of a second transpapillary gallbladder stent if placement of 2 stents was unsuccessful on the index ERCP (Figure 1, Table 1).Figure 1.: Two transpapillary double pigtail stents terminating in the gallbladder. Table 1. - Study results Single stent, n=51 Double stents, n=16 P value Total, n=76 Age, mean (SD) 69.6 (12.8) 69.6 (12.8) 0.65 69 (12.7) Female, n (%) 6 (11.8) 4 (25) 0.2 10 (13.2) CBD stone present, n (%) 20 (39.2) 6 (37.5) 0.9 49 (64.5) Indication, n (%) Reason for nonoperative status 0.27 Poor functional status 6 (11.8) 2 (13.3) 10 (13.3) Comorbidities 21 (41.2) 6 (40) 33 (44) Advanced malignancy 5 (9.8) 1 (6.7) 6 (8) Anticipated challenging surgery 15 (29.4) 2 (13.3) 17 (22.7) Multifactorial 4 (7.8) 5 (31.2) 10 (13.2) Cystic duct balloon dilation before placement, n (%) 29 (56.9) 12 (75) 0.19 43.4 (76) Prior percutaneous drain, n (%) 4 (7.8) 8 (50) < 0.001 13 (17.1) Diameter of the 1st stent, n (%) 0.06 5 Fr 3 (5.9) 0 (0) 3 (4.5) 7 Fr 29 (56.9) 15 (93.7) 44 (65.7) 8.5 Fr 10 (19.6) 1 (6.3) 11 (16.4) 10 Fr 9 (17.6) 0 (0) 9 (13.4) Clinical success, n (%) 45 (88.2) 15 (93.7) 0.53 61 (81.3) Unplanned reintervention, n (%) 11 (21.6) 0 (0) 0.04 11 (14.5) Adverse event, n (%) 4 (7.8) 1 (6.3) 0.83 5 (7.5) Cholangitis, n (%) 0 (0) 0 (0) - 0 (0) Perforation, n (%) 0 (0) 0 (0) - 0 (0) Post-ERCP pancreatitis, n (%) 2 (3.9) 1 (6.3) 0.69 3 (4)