Endoscopic Nasogallbladder Drainage in Patients with Acute Cholecystitis: What’s Predictive Factor for Technical Success?

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Although cholecystectomy is the treatment of choice in patients with acute cholecystitis, nonsurgical gallbladder de-compression may be preferable for patients of advanced age or underlying comorbidities such as liver cirrhosis or cardiopul-monary disease. Percutaneous and endoscopic drainage procedures are recommended as nonsurgical gallbladder drainage. Percutaneous transhepatic gallbladder drainage (PTGBD) is the most established technique for gallbladder drainage in patients unresponsive to medical treatments or who are at high risk for cholecystectomy, with clinical response rates of 90% to 100%. However, PTGBD may be not suitable for patients with massive ascites or coagulopathy or an inaccessible gallbladder location such as Chilaiditi syndrome. Adverse events related to PTGBD including puncture-induced hemorrhage, pneumothorax, and bile peritonitis was reported in 2.8% to 12% of patients. Endoscopic gallbladder drainage technique has been proposed as alternative therapy to PTGBD, including transpapillary nasogallbladder drainage (ENGBD), transpapillary gallbladder stenting, or endoscopic ultrasound-guided transmural gallblad-der drainage (EUS-GBD). ENGBD has been proposed as an alternative method to PTGBD more than 20 years ago. The reported technical success rates of ENGBD were 64% to 89%, which is lower than that reported for the percutaneous transhepatic approach. 4 ENGBD exhibits a low technical success rate as a result of technical challenging in cystic duct (CD) cannulation. The difficult reasons in negotiating the CD with the guidewire are as follows: First, the CD tortuosity and stricture caused by inflammation and gallstone impaction can block the advancement of the guidewire. Second, the point at which the CD takes off from the common bile duct (CBD) is frequently not visible on cholan-giograms. SpyGlass cholangioscopy has significant advantages over endoscopic retrograde cholangiopancreatography in allowing the direct visual examination of bile ducts and obtaining targeted CD cannulation. The recent study reported SpyGlass-assisted ENGBD is useful in patients with acute cholecystitis even when the CD is invisible on the cholangiograms. 5 Complications of ENGBD are mainly related to CBD cannulation (pan-creatitis) and sphincterotomy (perforation and bleeding). 6 CD cannulation can be difficult due to the cystic duct's corkscrew profile and narrow caliber, and the presence of Heister's valves. Despite the use of hydrophilic guidewire, CD injury that the guide wire penetrates through the cystic duct wall can occur. 6,7 EUS-GBD is recently introduced as an alternative therapy of acute cholecystitis in high-risk patients. The advantages of EUS-GBD are the avoidance …