Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited. Is Transpapillary Gallbladder Stenting Better than Percutaneous Cholecystostomy for the Treatment of Symptomatic Gallbladder Disease in Decompensated Cirrhotic Patients? To The Editor: We read with great interest the article by Tujios et al 1 about evaluation of the short-term and long-term out- comes in 34 consecutive decompensated cirrhotic patients with symptomatic gallbladder disease (SGD) undergoing transpapillary gallbladder stent (TGS) placement. They conclude that TGS is a minimally invasive, safe, and effective treatment for SGD in poor surgical candidates. However, we wish to highlight certain issues regarding the optimal form of management of SGD in poor surgical candidates. Cholecystectomy is the optimal treatment for SGD; however, in patients with poor general condition surgical treatment may carry a high risk of com- plications associated with major morbid- ity and mortality. In the abstract section, the authors specify 1 that “endoscopic TGS placement is a minimally invasive means of treating symptomatic gall- bladder disease in poor surgical can- didates.” However, referring to TGS method in the introduction section, they specify that “these high-risk and techni- cally challenging endoscopic therapies are not widely available; reports are limited to small retrospective case series (their study is also relatively small and retro- spective) with variable data on the indi- cations, complications, and long-term follow-up.” From our point of view, after a long experience in performing percu- taneous cholecystostomy (PC) and treating complications after surgical cholecystectomy, we agree that endo- scopic TGS is less aggressive compared with surgery but it is a much more aggressive a method compared with PC. 2–6 Numerous reports have already shown the efficacy of PC in the treat- ment of SGD in high-risk patients. 2–10 PC’s efficacy and practicality make it suitable for the treatment of SGD regardless of patients’ condition as it can be carried out without general anesthesia, with easier catheter manipulation, and monitoring of the drainage. Besides, with PC a few catheters can be simultaneously intro- duced into the gallbladder with fewer traumas, performing vigorous irriga- tion with similar or better effects than by TGS. However, it remains controversial up to now, if PC and TGS should be used as temporary measures to post- pone the definitive cholecystectomy to an elective setting, or if these proce- dures itself may be the definitive treatment. In the discussion section, 1 the authors specify that their “series also suggest that TGS may prove to be an effective long-term management approach to SGD in decompensated cirrhosis patients or perhaps stabilize them for future cholecystectomyy.” We had several cases of SGD in patients with poor general condition (some of them were decompensated cirrhotic patients) which were success- fully treated by PC. Our initial inten- tion was for PC to be used as a tem- porizing measure while awaiting optimization of underlying comorbid- ities before performing elective surgery. But, majority of those cases required no further surgical treatment after PC. 3,4 However, we are aware of the fact that the application of PC is not the appropriate method for treatment of SGD in all patients. The major advantage of endoscopic approach is that it creates a permanent bile drain- age into duodenum with no spillage of bile in contrast to PC, thereby reducing the risks of formation of bile-cuta- neous fistulas. Besides, PC is not practical for patients. However, with the drainage problems (which could appear with both techniques), mon- itoring, manipulation, or change of stent and the analysis of the bile con- tent are much easier using PC then TGS. Applicability of these techniques also depends on the availability of specialized expertise and a multi- disciplinary team dedicated to the management of SGD. Concluding, we believe that more open questions remain regarding the treatment of SGD. Large-scale and multicenter studies are needed to clearly determine which of these methods improve efficacy and safety, and provides better outcomes com- pared with other techniques in the treatment of SGD in decompensated cirrhotic patients. Despite its limi- tations, this study represents a sig- nificant step toward gaining more clarity in this matter. Enver Zerem, MD, PhD*w Safet Omerovic´, MD, PhDz Mirza Omerovic´, MDz Omar Zerem, BScy *Department of Medical Sciences, The Academy of Sciences and Arts of Bosnia and Herzegovina wDepartment of Gastroenterology University Clinical Center yMedical Faculty, University of Tuzla Tuzla zDepartment of Surgery, General Hospital Mostar, Mostar, Bosnia and Herzegovina REFERENCES 1. Tujios SR, Rahnama-Moghadam S, Elmunzer JB, et al. Transpapillary gallbladder stents can stabilize or improve decompensated cirrhosis in patients awaiting liver transplantation. J Clin Gastroenterol. 2014. [Epub ahead of print] doi: 10.1097/MCG.00000000 00000269. 2. Zerem E, Omerovic´ S. Minimally invasive management of biliary compli- cations after laparoscopic cholecystec- tomy. Eur J Intern Med. 2009;20: 686–689. 3. Zerem E, Omerovic´ S. Can percutane- ous cholecystostomy be a definitive management for acute cholecystitis in high-risk patients? Surg Laparosc Endosc Percutan Tech. 2014;24: 187–191. 4. Zerem E, Omerovic´ S. Can percutane- ous cholecystostomy be a definitive management for both acute calculous and acalculous cholecystitis? J Clin Gastroenterol. 2012;46:251. 5. Zerem E. Percutaneous versus endo- scopic approach in treatment of acute cholecystitis. Gastrointest Endosc. 2012; 75:226, author reply 226-227. 6. Zerem E, Omerovic´ S, Latic´ F. Com- ments on the article about the evaluation of the results of percutaneous cholecys- tostomy versus cholecystectomy. Ann The authors declare that they have nothing to disclose. LETTER TO THE EDITOR J Clin Gastroenterol  Volume 00, Number 00, ’’ 2015 www.jcge.com | 1