New Multidisciplinary Approach Manages Acute Cholecystitis in Era of EUS-Guided LAMS

Internationally recognized specialists at Orlando Health Digestive Health Institute Center for Advanced Endoscopy, Research and Education (CARE) have proposed a new endoscopic management strategy to better address gallbladder drainage in acute cholecystitis patients.

Acute cholecystitis is the third most common general surgical emergency in the United States with minimally invasive cholecystectomy being the mainstay of treatment.  However, for nonsurgical patients, the gallbladder is decompressed by placement of a percutaneous cholecystostomy tube. Although considered a temporary measure, a significant number of patients do not go on to have a cholecystectomy and instead retain these indwelling tubes for extended periods. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an emerging method for gallbladder decompression in a select cohort of high-risk surgical patients presenting with acute cholecystitis.

“EUS to internally decompress the inflamed gallbladder is being increasingly practiced in lieu of an indwelling percutaneous cholecystostomy tube,” says Shyam S. Varadarajulu, MD, president of Orlando Health Digestive Health Institute. “However, there have not been good guidelines for proper patient choice.”

To address this, the Orlando Health CARE team, under the direction of Dr. Varadarajulu and Ji Young Bang, MD, has outlined a new management strategy. Called the Orlando Proposal, this strategy uses a practical algorithm to guide endoscopic management of acute cholecystitis based on the clinical outcomes from a retrospective study of 25 high-risk surgical patients who underwent EUS-GBD over a 24-month period.

The Orlando Proposal takes a multidisciplinary approach to management of patient cohorts. “Our findings propose that EUS-GBD should be reserved for a selective group of never-surgery patients. It’s not for all patients broadly stratified as high-risk surgical candidates because some of them after resolution of the acute illness could become operable,” says Dr. Varadarajulu.

The study proposes that multidisciplinary consensus is essential to guide clinical management. “While laparoscopic cholecystectomy should be the treatment of choice in low- to moderate-risk patients, those deemed inoperable at presentation should be stratified to high-risk or never-surgery status,” says Dr. Varadarajulu. “For never-surgery patients, EUS-GBD should be considered destination therapy. In high-risk patients, percutaneous cholecystostomy or transpapillary cystic duct stenting at endoscopic retrograde cholangiopancreatography may be considered as a bridge to surgery, with patient reassessment at four to six weeks.”

The full-text manuscript of this groundbreaking research was recently published in the GUT journal.  

A referral center of excellence, Orlando Health Digestive Health Institute offers comprehensive and coordinated care for a multitude of digestive diseases, as well as leading-edge research and world-class education. Specialists provide tertiary clinical care across all subspecialty and general gastroenterology to evaluate, diagnose and treat a wide range of gastrointestinal conditions.

The Update - Orlando Health - One of Central Florida's Most Comprehensive Healthcare Networks