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Dr. Buch:
Welcome to GI Insights on ReachMD. I'm your host, Dr. Peter Buch. And joining us today to talk about endoscopic ultrasound-guided gallbladder drainage, or EUS drainage for short, is returning guest, Dr. Michel Kahaleh. Dr. Kahaleh is Chief of Endoscopy, Director of the Pancreas Program, and Medical Director of the Advanced Endoscopy Research Program at Robert Wood Johnson Medical School.
Dr. Kahaleh, welcome back to the program.
Dr. Kahaleh:
Thank you for having me back. I'm excited to be here.
Dr. Buch:
To start us off, Dr. Kahaleh, who are appropriate candidates for EUS drainage?
Dr. Kahaleh:
Yeah, this is a great question. Gallbladder drainage has completely changed the way we deal with cholecystitis and infection of the gallbladder. We are not trying to replace the gold standard of laparoscopy cholecystectomy. We are targeting those people who are poor candidates for this surgical technique, people that have cancer, are too old, or have a very bad heart to sustain any surgery. Those people may develop inflammation or infection of the gallbladder, and instead of offering them drainage through the skin, we now can drain them endoscopically.
Dr. Buch:
And when performing these procedures, what are the technical challenges you often encounter?
Dr. Kahaleh:
I think the biggest challenge is to be able to have an adequate window. So you have to be able to get down into the stomach or the small bowel and find a good window to deploy a stent between the gallbladder and the gut. That is the biggest challenge. If you don't have a window, you cannot perform this procedure.
Dr. Buch:
Now with that being said, when should we consider transpapillary gallbladder drainage instead of an EUS drainage?
Dr. Kahaleh:
I think the biggest problem of offering transpapillary gallbladder drainage is the ability to drain the bile duct. So you first have to drain the bile duct and then you have to go for the gallbladder, which means we offer this technique for people that need both the bile duct and the gallbladder drained or people that have a very bad window for the endoscopic ultrasound drainage.
Dr. Buch:
Thank you. For those just tuning in, you're listening to GI Insights on ReachMD. I'm Dr. Peter Buch, and I'm speaking with Dr. Michel Kahaleh about endoscopic ultrasound-guided gallbladder drainage.
So, Dr. Kahaleh, how do you minimize adverse events with EUS drainage?
Dr. Kahaleh:
I think it's very important to first do your homework. You need to get a nice cross-sectional imaging, like a CT scan of the abdomen or an MRI, to make sure that the patient has good coagulation, and you need to have an endoscopist that has been trained in this procedure. I recommend using an endoscopist that has been through an advanced endoscopy training program.
Dr. Buch:
And how many procedures before an endoscopist is competent to do these kinds of drainage procedures?
Dr. Kahaleh:
We recommend 20 to 30 of those procedures before embarking on doing them alone.
Dr. Buch:
And can you share the long-term outcomes you see among your patients who undergo EUS drainage?
Dr. Kahaleh:
So when a patient has terminal cancer and needs this procedure to relieve his gallbladder infection or inflammation, we tend to leave that stent in place, and typically the patient is comfortable until his end of life. For patients who have a very bad heart or a very bad medical condition forbidding surgery, sometimes once you do those procedures, you can actually optimize their medical picture. For instance, you can make sure their heart is getting better or you can make sure that their lungs are shaped up. And some of them end up sustaining surgery safely, so you can also use this procedure as a bridge to surgery.
Dr. Buch:
And when we're talking about the bridge to surgery, what percentage of patients would you say are able to get to the point that they can have formal standard surgery?
Dr. Kahaleh:
Probably 30 percent. So out of the 100 percent of patients that underwent this procedure, 30 percent can go to surgery, 30 percent of stent will remain in place until their end of life, and another 30 percent basically need a stent revision because they're going to live long enough to necessitate what we call recycling of the stent at some point.
Dr. Buch:
And can you just fill in our audience about how often you have to do stent recycling?
Dr. Kahaleh:
Typically after six months we remove the metal stent placed between the gallbladder and the gut. We tend to either remove it completely with no replacement if the gallbladder has completely collapsed, or we can sometimes pop two plastic stents just to keep it open and prevent the drainage to be eliminated.
Dr. Buch:
And when should we consider old-fashioned percutaneous gallbladder drainage instead of the procedures we've talked about today?
Dr. Kahaleh:
I think any patient that is bedridden, in the ICU, or unable to sustain any endoscopy might be a patient that will benefit from this. It's a minority of patients, but we still have some patients that are totally unable to sustain any endoscopy.
Dr. Buch:
Now before we conclude, Dr. Kahaleh, are there any other thoughts you would like to share with our audience today?
Dr. Kahaleh:
Yeah. I think the biggest thought that I would like to share with the audience is it's always important to consider the most minimally invasive intervention when you're dealing with those patients because, ultimately, patients are living longer and patients are able to beat cancer for far longer than you can imagine, so it's crucial for us to always think "Can I offer a more minimally invasive option to that patient?"
Dr. Buch:
Thank you so much. That brings us to the end of today's program. I want to thank my guest, Dr. Michel Kahaleh, for helping us better understand endoscopic ultrasound-guided gallbladder drainage.
Dr. Kahaleh, it was a pleasure having you on the program.
Dr. Kahaleh:
It was my pleasure, as well.
Dr. Buch:
For ReachMD, I'm Dr. Peter Buch. To access this and other episodes in this series, visit ReachMD.com/GIInsights where you can Be Part of the Knowledge. Thanks for listening.
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Endoscopic ultrasound-guided gallbladder drainage (ESU) is used to treat patients with cholecystitis and infection of the gallbladder. So when should we be utilizing ESU, and what are some common challenges associated with this procedure? Joining Dr. Peter Buch to explore this topic is Dr. Michel Kahaleh, Chief of Endoscopy, Director of the Pancreas Program, and Medical Director of the Advanced Endoscopy Research Program at Robert Wood Johnson Medical School.
Endoscopic ultrasound-guided gallbladder drainage (ESU) is used to treat patients with cholecystitis and infection of the gallbladder. So when should we be utilizing ESU, and what are some common challenges associated with this procedure? Joining Dr. Peter Buch to explore this topic is Dr. Michel Kahaleh, Chief of Endoscopy, Director of the Pancreas Program, and Medical Director of the Advanced Endoscopy Research Program at Robert Wood Johnson Medical School.
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