EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent placement should replace PTBD after ERCP failure in patients with distal tumoral biliary obstruction: a large real-life study

Technical failure of endoscopic ultrasound-guided choledochoduodenostomy: multicenter study on rescue techniques, consequences, and risk factors

BACKGROUND

 We aimed to determine risk factors for technical failure of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS), evaluate short- and long-term consequences, and identify salvage techniques in patients with biliary obstruction.

METHODS

 This retrospective multicenter study of EUS-CDS (2018-2024) included technical failure, classified as type 1 (digestive flange mispositioned), type 2 (biliary flange mispositioned), type 3 (stent deployment failure), type 4 (catheter/lumen-apposing metal stent [LAMS] through the bile duct), and type 5 (others). Controls were successful EUS-CDS in the same center and period. The primary end point was risk factors for failure. Secondary end points were endoscopic rescue techniques and immediate- and long-term consequences.

RESULTS

 Technical failure occurred in 7 % (95 %CI 5-9). Across 23 centers, 296 patients were analyzed (mean age 71 [SD 16] years, 53 % male), including 100 technical failures: type 1 (26 %), type 2 (41 %), type 3 (11 %), type 4 (6 %), type 5 (16 %). Risk factors for technical failure in multivariate analysis included CBD diameter ≤ 15 mm, duodenal stenosis, wired technique, and low operator experience (≤ 10 LAMS). Endoscopic salvage was successful in 77 %, with 53 % using a covered metal stent and 22 % using a new LAMS. Early failures were mild in 56 % of cases, but 12 % resulted in death within 30 days. Immediate endoscopic salvage reduced severe clinical adverse events (P < 0.001) and increased success rates (P < 0.001).

CONCLUSIONS

 EUS-CDS failures were not rare and were severe in half of cases. Recognizing risk factors, identifying failures during the procedure, and knowing endoscopic salvage methods are crucial.

Endoscopic Ultrasound-guided Transmural Biliary Drainage With 6 mm and 8 mm Cautery-enhanced Lumen-apposing Metal Stents: A Multicenter Collaborative Study

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP) may be unsuccessful in patients with duodenal stenosis or malignant ampullary infiltration. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been proposed as an alternative. We aimed to assess the efficacy and safety of EUS-BD for malignant distal bile duct obstruction using the newly introduced smaller caliber 6 or 8 mm cautery-enhanced lumen-apposing metal stent.

METHODS

A multicenter retrospective study was performed on patients with unresectable malignant distal bile duct obstruction who underwent EUS-BD between 2021 and 2022 after unsuccessful ERCP.

RESULTS

Thirty-two patients were included [7 (53.13%) males], with a mean age of 72.2 ± 12.5 years. The technical success rate was 100%. Altered anatomy was present in 2 (6.25%). The indication for drainage was biliary obstruction from pancreatic cancer in 26 patients (84.5%), cholangiocarcinoma in 3 (9.4%), and ampullary mass in 3 (9.4%). The procedure was performed mostly in an outpatient setting (n = 19, 59.38%). The clinical success rate was 92.3% [bilirubin: 14.1 (SD: 8.9) preprocedure vs 4.9 (SD: 1.1) postprocedure; P = 0.0001]. There was one early adverse event of a perforation, which was closed endoscopically and drained percutaneously. Delayed adverse events included food impaction of the stent (n = 1), which was resolved with a repeat procedure and insertion of a double pigtail stent.

CONCLUSION

This study demonstrates the feasibility of EUS-BD drainage using smaller caliber 6 or 8 mm lumen-apposing metal stent to relieve malignant distal bile duct obstruction in patients who fail conventional ERCP.

A meta-analysis of the effectiveness and safety of endoscopic ultrasound-guided choledochoduodenostomy employing electrocautery-enhanced lumen-apposing metal stents for biliary drainage after failed endoscopic retrograde cholangiopancreatography

Objectives

Endoscopic ultrasound-biliary drainage and choledochoduodenostomy (EUS-CDD) are increasingly being used as alternative procedures for biliary drainage in patients in whom endoscopic retrograde cholangiopancreatography fails. Novel electrocautery-enhanced lumen-apposing metal stents (EC-LAMS) are expected to be widely used for EUS-CDD. We performed a systematic review and meta-analysis to evaluate the technical and clinical success of EUS-CDD using EC-LAMS.

Methods

We performed a comprehensive search of several databases from inception to May 2022 to search for relevant studies on the effectiveness and safety of endoscopic ultrasound-guided biliary drainage using EC-LAMS. The pooled rates of technical success, clinical success, and early and late adverse events were calculated.

Results

Ten studies with a total of 481 patients were included in this analysis. The overall technical success rate was 94.3%, 95% confidence interval [CI] (91.5%-96.2%), The overall clinical success rate was 94.9%, 95% CI (92%-96.7%). The overall early adverse event rate was 5.1%, 95% CI (3.4%-7.8%), and the overall late adverse event rate was 10.8%, 95% CI (6.6%-17.2%).

Conclusion

In patients with biliary obstruction with failed endoscopic retrograde cholangiopancreatography, EUS-CDD using EC-LAMS is a good alternate management option with a high success rate and relatively low adverse events.

Effectiveness of endoscopic ultrasound (EUS)-guided choledochoduodenostomy vs. EUS-guided gallbladder drainage for jaundice in patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography: Retrospective, multicenter study (GALLBLADEUS Study)

OBJECTIVES

The aim of this study was to compare endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) vs. EUS-gallbladder drainage (EUS-GBD) in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) for jaundice resulting from malignant distal biliary obstruction (MDBO).

METHODS

This multicenter retrospective study included patients with obstructive jaundice secondary to MDBO who underwent EUS-GBD or EUS-CDS with lumen-apposing metal stents after failed ERCP. The primary end-point was clinical success rate. Secondary end-points were technical success, periprocedural adverse events rate (<24 h), late adverse events rate (>24 h), overall survival, and time to recurrent biliary obstruction.

RESULTS

A total of 78 patients were included: 41 underwent EUS-GBD and 37 underwent EUS-CDS. MDBO was mainly the result of pancreatic cancer (n = 63/78, 80.7%). Clinical success rate was similar for both procedures: 87.8% for EUS-GBD and 89.2% for EUS-CDS (P = 0.8). Technical success rate was 100% for EUS-GBD and 94.6% for EUS-CDS (P = 0.132). Periprocedural morbidity (<24 h) rates were similar between both groups: 4/41 (9.8%) for EUS-GBD and 5/37 (13.5%) for EUS-CDS (P = 0.368). There was a significantly higher rate of late morbidity (>24 h) among patients in the EUS-CDS group (8/37 [21.6%]) than in the EUS-GBD group (3/41 [7.3%]) (P = 0.042). The median follow-up duration was 4.7 months. Overall survival and time to recurrent biliary obstruction did not significantly differ between the groups.

DISCUSSION

After failed ERCP for MDBO, EUS-GBD and EUS-CDS show comparable clinical success rates and technical success. EUS-GBD appears to be a promising alternative for MDBO, even as a second-line treatment after failed ERCP. Further studies are needed to validate these findings and compare the long-term outcomes of EUS-GBD and EUS-CDS.

ASGE Standards of Practice Committee, Pawa S, Marya NB, Thiruvengadam NR, Ngamruengphong S, Baron TH, Bun Teoh AY, Bent CK, Abidi W, Alipour O, Amateau SK, Desai M, Chalhoub JM, Coelho-Prabhu N, Cosgrove N, Elhanafi SE, Forbes N, Fujii-Lau LL, Kohli DR, Machicado JD, Navaneethan U, Ruan W, Sheth SG, Thosani NC, Qumseya BJ, (ASGE Standards of Practice Committee Chair). American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for the role of therapeutic EUS in the management of biliary tract disorders. This guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses the following: 1: The role of EUS-guided biliary drainage (EUS-BD) versus percutaneous transhepatic biliary drainage (PTBD) in resolving biliary obstruction in patients after failed ERCP. 2: The role of EUS-guided hepaticogastrostomy versus EUS-guided choledochoduodenostomy in resolving distal malignant biliary obstruction after failed ERCP. 3: The role of EUS-directed transgastric ERCP (EDGE) versus laparoscopic-assisted ERCP and enteroscopy-assisted ERCP (E-ERCP) in resolving biliary obstruction in patients with Roux-en-Y gastric bypass (RYGB) anatomy. 4: The role of EUS-BD versus E-ERCP and PTBD in resolving biliary obstruction in patients with surgically altered anatomy other than RYGB. 5: The role of EUS-guided gallbladder drainage (EUS-GBD) versus percutaneous gallbladder drainage and endoscopic transpapillary transcystic gallbladder drainage in resolving acute cholecystitis in patients who are not candidates for cholecystectomy.

Adverse events in endoscopic ultrasound-guided choledochoduodenostomy with lumen-apposing metal stents: A systematic review and meta-analysis

BACKGROUND AND AIM

Several meta-analyses have analyzed the technical and clinical success of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) by using lumen-apposing metal stents (LAMS) in malignant biliary obstruction, but those concerning adverse events (AEs) are scarce. The current systematic review and meta-analysis was conducted to evaluate the AEs after EUS-CDS with LAMS.

METHODS

A comprehensive literature search of PubMed, Embase, Scopus, Web of Science, and the Cochrane Library was conducted for studies reporting the outcomes of EUS-CDS with LAMS. The main endpoints were the incidence of overall and specific AEs. Moreover, the stent dysfunction, and reintervention rates were evaluated independently.

RESULTS

A total of 21 studies (n = 1438) were included in the final meta-analysis. The pooled rate of technical and clinical success was 93.5% (95% confidence interval [CI]: 91.3-95.1) and 88.0% (95% CI: 83.9-91.1), respectively. After EUS-CDS with LAMS, the pooled incidence of overall AEs was 20.1% (95% CI: 16.0-24.9). The estimated rate of early AEs was 10.6% (95% CI: 7.9-14.2), and late AEs was 11.2% (95% CI: 8.2-15.2). Infection/cholangitis was the commonest AE, with a pooled incidence of 6.1% (95% CI: 3.7-10.1). The estimated incidence of stent dysfunction and reintervention was 10.5% (95% CI: 7.5-14.4), and 12.1% (95% CI: 9.3-15.7), respectively.

CONCLUSION

Despite with a high technical and clinical success rate, EUS-CDS with LAMS may be associated with overall AEs and stent dysfunction in one-fifth and one-tenth of cases, respectively. Further efforts are required to optimize its safety and long-term stent patency.

Endoscopic-ultrasound-guided biliary drainage with placement of electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction: Updated meta-analysis

BACKGROUND

Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced (ECE) delivery of lumen-apposing metal stent (LAMS) is gradually being recognized as a viable palliative technique for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography (ERCP) failure. However, most of the studies that have assessed its efficacy and safety were small and heterogeneous. Prior meta-analyses of six or fewer studies that were published 2 years ago were therefore underpowered to yield convincing evidence.

AIM

To update the efficacy and safety of ECE-LAMS for treatment of biliary obstruction after ERCP failure.

METHODS

We searched PubMed, EMBASE, and Scopus databases from the inception of the ECE technique to May 13, 2022. Primary outcome measure was pooled technical success rate, and secondary outcomes were pooled rates of clinical success, reintervention, and adverse events. Meta-analysis was performed using a random-effects model following Freeman-Tukey double-arcsine transformation in R software (version 4.1.3).

RESULTS

Fourteen eligible studies involving 620 participants were ultimately included. The pooled rate of technical success was 96.7%, and clinical success was 91.0%. Adverse events were reported in 17.5% of patients. Overall reintervention rate was 7.3%. Subgroup analyses showed results were generally consistent.

CONCLUSION

ECE-LAMS has favorable success with acceptable adverse events in relieving biliary obstruction when ERCP is impossible. The consistency of results across most subgroups suggested that this is a generalizable approach.

Complications and management of interventional endoscopic ultrasound: A critical review

In the last decades, Endoscopic ultrasound (EUS) has rapidly grown and evolved from being mainly a diagnostic procedure, to being an interventional and therapeutic tool in several pathological clinical scenarios. With the progressive growth in technical expertise and dedicated devices, interventional endoscopic ultrasound procedures (IEUSP) have shown high rates of technical and clinical success, together with a relatively safe profile. However, the description and the standardization of different and specific types of adverse events (AEs) are still scarce in literature, and, consequently, even less the management of AEs. The aim of this study is to critical review and to describe AEs related to each of the main IEUSP, and to provide an overview on the possible management strategies of endoscopic complications. Future studies and guidelines are surely required to reach a better standardization of different AEs and their best management.

Outcomes predictors in endoscopic ultrasound-guided choledochoduodenostomy with lumen-apposing metal stent: Systematic review and meta-analysis

Background and study aims EUS-guided choledochoduodenostomy (EUS-CDS) is a minimally invasive procedure used to treat malignant biliary obstruction (MBO) by transduodenal placement of a lumen-apposing metal stent (LAMS) into the extrahepatic bile duct. To identify factors that contribute to safe and effective EUS-CDS using LAMS, we performed a systematic review of the literature and meta-analysis. Methods The methodology of our analysis was based on PRISMA recommendations. Electronic databases (Medline, Scopus, EMBASE) were searched up to November 2022. Full articles that included patients with distal malignant biliary obstruction who underwent EUS-CDS using LAMS after failed endoscopic retrograde cholangiopancreatography were eligible. Random-effect meta-analysis was performed reporting pooled rates of technical success, clinical success, and adverse events (AEs) by means of a random model. Multivariate meta-regression and subgroup analysis were performed to assess possible associations between the outcomes and selected variables to assess the correlation between outcomes and different variables. Results were also stratified according to stent size. Results Twelve studies with 845 patients were included in the meta-analysis. Pooled technical and clinical success rates were 96% (95% confidence interval [CI] 94%-98%; I 2 = 52.29%) and 96% (95%CI 95%-98%), respectively, with no significant association with baseline characteristics, such are sex, age, common bile duct diameter, or stent size. The pooled AE rate was 12% (95%CI: 8%-16%; I 2 = 71.62%). The AE rate was significantly lower when using an 8 × 8 mm stent as compared with a 6 × 8 mm LAMS (odds ratio 0.59, 0.35-0.99; P = 0.04), with no evidence of heterogeneity (I 2 = 0%). Conclusions EUS-CDS with LAMS is a safe and effective option for relief of MBO. Selecting an appropriate stent size is crucial for achieving optimal safety outcomes.

Therapeutic Endoscopic Ultrasound for Complications of Pancreatic Cancer

Progression of pancreatic adenocarcinoma can result in disease complications such as biliary obstruction and gastric outlet obstruction. The recent advances in endoscopic ultrasound (EUS) have transformed EUS from a purely diagnostic technology to a therapeutic modality, particularly with the development of lumen-apposing metal stents. In terms of biliary drainage, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy offer safe and effective techniques when conventional transpapillary stent placement via ERCP fails or is not possible. If these modalities are not feasible, EUS-guided gallbladder drainage offers yet another salvage technique when the cystic duct is non-involved by the cancer. Lastly, EUS-guided gastroenterostomy allows for an effective bypass treatment for cases of gastric outlet obstruction that enables patients to resume eating within several days. Future randomized studies comparing these techniques to current standard-of-care options are warranted to firmly establish therapeutic EUS procedures within the treatment algorithm for this challenging disease.

Safety and efficacy of lumen-apposing metal stents and double-pigtail plastic stents for endoscopic ultrasound-guided drainage of walled-off necrosis; a systematic review and meta-analysis

BACKGROUND

Patients with walled-off necrosis (WON) are still challenging to treat safely and effectively. Recently, double-pigtail plastic stents (DPS), bi-flanged metallic stents (BFMS), and lumen-apposing metal stents (LAMS) have been employed with endoscopic ultrasound-guided (EUS-guided) drainage. However, there is little solid evidence to support the effectiveness and safety of using stents. This study aims to compare the outcomes of the LAMS and the PS.

METHOD

Till July 2022, a thorough database search was done, and studies that met the criteria were chosen. By using the RevMan software, the technical and clinical success and other secondary outcomes were calculated. Subgroup analysis was performed between the LAMS and the BFMS.

RESULTS

Fifteen studies (two randomized controlled trials and thirteen observational) with 687 patients receiving metal stents and 771 patients receiving plastic stents were selected for final analysis. There was no significant risk of bias or publication bias. The odds ratios (OR) for technical and clinical success were 0.36 (95% confidence interval (95% CI) 0.08, 1.52) and 2.26 (95%CI 1.62, 3.15), respectively. The OR for overall adverse events was 0.74 (95% CI 0.41, 1.34). In subgroup analysis, the LAMS and the BFMS showed the same outcomes.

CONCLUSION

Compared to DPS, LAMS had better clinical outcomes and fewer side effects when treating patients with WON.

Clinical application and follow-up of electrocautery-enhanced lumen-apposing metal stents for endoscopic ultrasonography-guided interventions

Aim: The lumen-apposing metal stent (LAMS) is a new device that expands the scope of gastrointestinal intervention under endoscopy. LAMS was initially used for the treatment of pancreatic fluid collections (PFCs), but is increasingly being used off-label. The electrocautery system simplifies the deployment of LAMS, making it more suitable for off-label situations. The short-term results of electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) are satisfactory; however, the long-term follow-up results must be evaluated. The aim of this article is to review the expanded clinical application of ECE-LAMS, the clinical value of on-label and off-label use, and follow-up results.Methods: After searching in PubMed and Web of Science databases using 'electrocautery-enhanced lumen-apposing metal stents' and 'endoscopic ultrasonography (EUS) -guided interventions' as keywords, studies related were compiled and examined.Results: ECE-LAMS are widely used for on-label and off-label situations. The short-term and long-term results of ECE-LAMS are satisfactory, but there are still some studies that do not agree with this viewpoint.Conclusion: The clinical application of ECE-LAMS is relatively safe and reliable but more well-designed randomized trials and prospective studies are needed to evaluate the impact of this technology on therapeutic EUS, to improve the safety and success rate of EUS-guided LAMS implantation, and to expand its application in other indications.

Real-life Indications and Outcome of Electrocautery-enhanced Lumen-apposing Metal Stents in a Tertiary Center

PURPOSE

Electrocautery-enhanced lumen-apposing stents (EC-LAMS) were originally designed for the drainage of the gallbladder, bile duct, and pancreas pseudocysts. Throughout the years, several off-label indications were established. This study aims to evaluate the indication, safety, efficacy, and outcome of all LAMS implanted in a single tertiary referral center.

METHODS

From April 2016 to April 2022, all patients undergoing LAMS placement in a single tertiary center were included. We present a detailed analysis of indications, success rates, and complications based on a retrospective analysis of our prospectively maintained database.

RESULTS

A total of 86 stents were placed in 77 patients between April 2016 and April 2022. Indications were walled-off pancreatic necrosis (25.6%), bile duct obstructions (16.3%), acute cholecystitis (15.1%), pancreas pseudocysts (15.1%), postoperative collections (10.5%), postoperative pancreatic fistulas (9.3%), and gastro-gastrostomy/jejunostomy (8.1%) to enable to perform an endoscopic retrograde cholangiopancreatography in patients with gastric bypass. Technical success was 97.7% (84 out of 86). A total of 10 (11.7%) adverse events were observed. In 3 patients (3.5%), severe complications occurred, which required acute surgery; one displacement was closed through clips. In 7 patients (8.2%), bleedings occurred during necrosectomy or from mucosal erosions at the stent side, respectively, that were treated with endoclips.

CONCLUSIONS

EC-LAMS are safe and show a high technical success rate in all indications. In everyday clinical practice, the main indications are hepato-pancreato-biliary, and therefore an hepato-pancreato-biliary-surgical department should have EC-LAMS in their armamentarium.

Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.

METHODS

A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.

RESULTS

One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%).

CONCLUSIONS

Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.

Endoscopic Ultrasound-guided Versus Percutaneous Transhepatic Biliary Drainage After Failed ERCP: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may fail to achieve biliary drainage in 5% to 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) are alternative therapeutic options in such cases. The present meta-analysis aimed to compare the efficacy and safety of EUS-BD and PTBD for biliary decompression after failed ERCP.

METHODS

A comprehensive search of literature from inception to September 2022 was done of 3 databases for studies comparing EUS-BD and PTBD for biliary drainage after failed ERCP. Odds ratios (ORs) with 95% CIs were calculated for all the dichotomous outcomes. Continuous variables were analyzed using mean difference (MD).

RESULTS

A total of 24 studies were included in the final analysis. Technical success was comparable between EUS-BD and PTBD (OR=1.12, 0.67-1.88). EUS-BD was associated with a higher clinical success rate (OR=2.55, 1.63-4.56) and lower odds of adverse events (OR=0.41, 0.29-0.59) compared with PTBD. The incidence of major adverse events (OR=0.66, 0.31-1.42) and procedure-related mortality (OR=0.43, 0.17-1.11) were similar between the groups. EUS-BD was associated with lower odds of reintervention with an OR of 0.20 (0.10-0.38). The duration of hospitalization (MD: -4.89, -7.73 to -2.05) and total treatment cost (MD: -1355.46, -2029.75 to -681.17) were significantly lower with EUS-BD.

CONCLUSIONS

EUS-BD may be preferred over PTBD in patients with biliary obstruction after failed ERCP where appropriate expertise is available. Further trials are required to validate the findings of the study.

Endoscopic Ultrasound-Guided Gallbladder Drainage for Malignant Biliary Obstruction: A Systematic Review

BACKGROUND

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a rescue technique for patients with malignant biliary obstruction who fail conventional treatment with ERCP or EUS-guided biliary drainage. The technique has been successfully employed in the management of acute cholecystitis in patients not fit for surgery. However, the evidence for its use in malignant obstruction is less robust. This review article aims to evaluate the data available at present to better understand the safety and efficacy of EUS-guided gallbladder drainage.

METHODS

A detailed literature review was conducted and several databases were searched for any studies relating to EUS-GBD in malignant biliary obstruction. Pooled rates with 95% confidence intervals were calculated for clinical success and adverse events.

RESULTS

Our search identified 298 studies related to EUS-GBD. The final analysis included 7 studies with 136 patients. The pooled rate of clinical success (95% CI) was 85% (78-90%, I2: 0%). The pooled rate of adverse events (95% CI) was 13% (7-19%, I2: 0%). Adverse events included: peritonitis, bleeding, bile leakage, stent migration, and stent occlusion. No deaths directly related to the procedure were reported; however, in some of the studies, deaths occurred due to disease progression.

CONCLUSION

This review supports the use of EUS-guided gallbladder drainage as a rescue option for patients who have failed conventional measures.

Efficacy and safety of EUS-guided biliary drainage for benign biliary obstruction - A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

ERCP is the first line of treatment for benign and malignant biliary obstruction and EUS-guided biliary drainage (EUS-BD) is usually used for patients who have failed ERCP. Recently, several studies have evaluated the role of EUS-BD in the management of benign biliary obstruction. This meta-analysis evaluates the efficacy and safety of EUS-BD in the management of benign biliary obstruction.

METHODS

We reviewed several databases from inception to July 8, 2022, to identify studies evaluating the efficacy and safety of EUS-BD in the management of benign biliary obstruction. Our outcomes of interest were technical success, clinical success, and adverse events. Pooled rates with 95% confidence intervals (CIs) for all outcomes were calculated using a random effects model. Subgroup analyses were performed including patients with normal anatomy versus surgically altered anatomy (SAA). Heterogeneity was assessed by I2 statistic.

RESULTS

We included 14 studies with 329 patients. The pooled rate (95% CI) of technical success was 88% (83%, 92%). The pooled rate (95% CI) of technical success for patients with SAA and normal anatomy was 92% (85%, 96%) and 83% (75%, 89%), respectively. The pooled rates (95% CI) of clinical success and adverse events were 89% (83%, 93%) and 19% (13%, 26%), respectively. We found low heterogeneity in most of the analyses.

CONCLUSIONS

EUS-BD is an effective and safe option in patients with benign biliary obstruction and should be considered after a failed attempt at ERCP or when ERCP is not technically possible.

Risk factors for stent dysfunction during long-term follow-up after EUS-guided biliary drainage using lumen-apposing metal stents: A prospective study

Background

EUS-guided choledoco-duodenostomy using electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) is becoming the gold standard in case of endoscopic retrograde cholangio-pancreatography failure for distal malignant obstruction. Long-term data in larger samples are lacking.

Methods

This was a prospective monocentric study including all patients who underwent EUS-guided choledochoduodenostomy (CDS) between September 2016 and December 2021. The primary endpoint was the rate of biliary obstruction during follow-up. Secondary endpoints were technical and clinical success rates, adverse event rates, and identification of risk factors for biliary obstruction.

Results

One hundred and twenty-three EUS-guided CDS using ECE-LAMS were performed at Limoges University Hospital were performed during the study period and included in the study. The main cause of obstruction was pancreatic adenocarcinoma in 91 (74.5%) cases. The technical and clinical success rates were 97.5% and 91%, respectively. Twenty patients (16.3%) suffered from biliary obstructions during a mean follow-up of 242 days. The clinical success rate for endoscopic desobstruction was 80% (16/20). In uni- and multivariate analyses, only the presence of a duodenal stent (odds ratio [OR]: 3.6, 95% confidence interval [CI] 95%: 1.2-10.2; P = 0.018) and a bile duct thinner than 15 mm (OR: 3.9, CI 95%: 1.3-11.7; P = 0.015) were the significant risk factors for biliary obstruction during the follow-up.

Conclusion

Obstruction of LAMS occurred in 16.3% of cases during follow-up and endoscopic desobstruction is efficacious in 80% of cases. The presence of duodenal stent and a bile duct thinner than 15 mm are the risk factors of obstruction. Except in these situation, EUS-CDS with ECE-LAMS could be proposed in the first intent in case of distal malignant obstruction.

Reduction of Lams-Related Adverse Events with Accumulating Experience in a Large-Volume Tertiary Referral Center

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMSs) are increasingly used both for on- and off-label indications. We continuously adapt our step-by-step protocol to optimize the safe deployment of LAMSs for the different indications. The aim of this study was to evaluate the impact of this approach over time.

METHODS

We conducted a single-center study on consecutive patients who underwent LAMS placement for on- and off-label indications between June 2020 and June 2022. Endpoints included technical success, clinical success and adverse event rates. We compared the results with our previously published early experience with LAMSs (N = 61), between March 2018 and May 2020.

RESULTS

This cohort consisted of 168 LAMSs in 153 patients. Almost half of them (47.6%) were placed for off-label indications (gastro-enterostomy, temporary access to the excluded stomach in patients with previous gastric bypass, drainage of postsurgical collections, stenting of short refractory gastrointestinal strictures). While the technical and clinical success rates were similar to those in our previously published cohort (97% and 93.5% versus 93.4% and 88.5%, respectively), the adverse event rate dropped from 21.3% to 8.9%.

CONCLUSIONS

Our results demonstrate the impact of a learning curve in LAMS placement, with a clinically relevant drop in LAMS-related adverse events over time.

Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) begins with successful biliary cannulation. However, it is not always be successful. The failure of the initial ERCP is attributed to two main aspects: the papilla/biliary orifice is endoscopically accessible, or it is inaccessible. When the papilla/biliary orifice is accessible, bile duct cannulation failure can occur even with advanced cannulation techniques, including double guidewire techniques, transpancreatic sphincterotomy, needle-knife precut papillotomy, or fistulotomy. There is currently no consensus on the next steps of treatment in this setting. Therefore, this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation. These options include interval ERCP, percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RV), and endoscopic ultrasound-assisted rendezvous procedures (EUS-RV). The overall success rate for interval ERCP was 76.3% (68%-79% between studies), and the overall adverse event rate was 7.5% (0-15.9% between studies). The overall success rate for PTE-RV was 88.7% (80.4%-100% between studies), and the overall adverse event rate was 13.2% (4.9%-19.2% between studies). For EUS-RV, the overall success rate was 82%-86.1%, and the overall adverse event rate was 13%-15.6%. Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise, facilities, or other specialists, it can be considered the first choice for salvage therapy. EUS-RV can also be considered if local experts are available. For patients in urgent need of biliary drainage, PTE-RV should be considered.

Multicenter study of lumen-apposing metal stents with or without pigtail in endoscopic ultrasound-guided biliary drainage for malignant obstruction-BAMPI TRIAL: an open-label, randomized controlled trial protocol

BACKGROUND

It is unclear whether the insertion of an axis-orienting double-pigtail plastic stent (DPS) through biliary lumen-apposing meal stent (LAMS) in EUS-guided choledochoduodenostomy (CDS) improves the stent patency. The aim of this study is to determine whether this technical variant offers a clinical benefit in EUS-guided biliary drainage (BD) for the management of distal malignant biliary obstruction.

METHODS/DESIGN

This is a multicenter open-label, randomized controlled trial with two parallel groups. Eighty-four patients with malignant biliary obstruction will undergo EUS-BD (CDS type) using LAMS in 7 tertiary hospitals in Spain and will be randomized to the LAMS and LAMS plus DPS groups. The primary endpoint is the rate of recurrent biliary obstruction, as a stent dysfunction parameter, detected during follow-up. Secondary endpoints: technical and clinical success (reduction in bilirubin > 50% within 14 days of stent placement), safety, and others (number of reinterventions, time to biliary obstruction, prognostic factors, survival rate).

DISCUSSION

The BAMPI trial has been designed to determine whether the addition of a coaxial axis-orienting DPS through LAMS is superior to LAMS alone to prevent stent dysfunction.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04595058 . Registered on October 14, 2020.