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HOME > Clin Endosc > Volume 57(6); 2024 > Article
Letter to the Editor Technical challenges and safety of prophylactic gallbladder stenting with metallic biliary stenting
Masood Muhammad Karim,orcid, Om Parkashorcid
Clinical Endoscopy 2024;57(6):841-842.
DOI: https://doi.org/10.5946/ce.2024.193
Published online: October 24, 2024

Section Gastroenterology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan

Correspondence: Masood Muhammad Karim Section Gastroenterology, Medicine Department, Aga Khan University Hospital, Stadium road ,Karachi 74800, Pakistan E-mail: masoodkareem37@gmail.com
• Received: July 14, 2024   • Revised: August 9, 2024   • Accepted: August 11, 2024

© 2024 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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This letter to the editor is in response to “Prophylactic endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis induced after metallic stent placement for malignant biliary strictures: a retrospective study, Japan”.1
The study by Kozakai et al.1 was informative and interesting. In this single-center, retrospective study, the author described their experience with the prophylactic role of gallbladder stenting (GBS) in malignant biliary strictures with metallic stenting to prevent acute cholecystitis (AC), which has a prevalence of 5.3%–12.1%.2
This study was conducted with the intention and effort to overcome the important complication of post self-expendible metallic stent (SEMS) deployment in malignant biliary patients, which demonstrated promising results. In particular, the difference in the incidence of AC between the GBS group and the control group was statistically significant (p=0.043). However, some concerns have arisen regarding the technical challenges, practicality, and safety of this procedure.
First, how do we select the ideal patients for this procedure? Selecting patients based on cholangiography alone before SEMS placement can lead to imprecise judgments, resulting in variability in opinion among endoscopists. Besides, the author could have mentioned the stricture and cystic duct opening distances, which could have been determined preoperatively on cross-sectional imaging.
Second, cystic duct cannulation and stenting are difficult because of their small caliber and tortuous anatomy; technical success is usually low, even in patients with stone disease (choledocholithiasis) without malignant stricture, and a cholangioscopy is required in most cases.
A study by Ridtitid et al.3 showed 64.2% technical success, which improved to 84% with cholangioscopy, however, still exhibited 15.4% cystic duct cannulation failure. However, this study had a relatively low technical success rate (70%). This evidence suggests that GBS should not be practiced at every center, and the ideal locations for such procedures must be well-equipped high-volume centers.
Third, safety is the most important parameter to consider before adopting a procedure. We found a significant number of adverse events in the GBS group (26.7%), which was twice the risk of AC (5.3%–12.1%). Compared with the control group (26.7% vs.13.3%), the GBS group had double the number of adverse events, with one of three cystic duct perforations (3.3%).
In conclusion, we recommend that GBS be performed in well-equipped high-volume centers with experienced endoscopists instead of in every endoscopy suite, owing to its technical and safety concerns.
  • 1. Kozakai F, Kanno Y, Koshita S, et al. Prophylactic endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis induced after metallic stent placement for malignant biliary strictures: a retrospective study, Japan. Clin Endosc 2024;57:647–655.Article
  • 2. Isayama H, Kawabe T, Nakai Y, et al. Cholecystitis after metallic stent placement in patients with malignant distal biliary obstruction. Clin Gastroenterol Hepatol 2006;4:1148–1153.ArticlePubMed
  • 3. Ridtitid W, Faknak N, Piyachaturawat P, et al. Intermediate- to long-term outcomes of endoscopic transpapillary gallbladder stenting in patients with gallstone-related disease: a 10-year single-center experience. Endoscopy 2023;55:469–475.ArticlePubMed

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        Technical challenges and safety of prophylactic gallbladder stenting with metallic biliary stenting
        Clin Endosc. 2024;57(6):841-842.   Published online October 24, 2024
        DOI: https://doi.org/10.5946/ce.2024.193
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