Biliary drainage in patients with malignant distal biliary obstruction: results of an Italian consensus conference

EUS-guided gallbladder drainage as a rescue in distal malignant biliary obstruction: A systematic review with meta-analysis

Patients with distal malignant biliary obstruction (dMBO) needing biliary drainage (BD) undergo ERCP as a first approach. EUS-guided gallbladder drainage (EUS-GBD) is now accepted as a rescue alternative for the palliation of jaundice in those patients with dMBO who fail ERCP and cannot undergo EUS-BD. This is a systematic review with meta-analysis for evaluating the efficacy and safety of EUS-GBD in this scenario. A comprehensive search through the main database platforms was conducted to May 2024. Pooled estimates were obtained using a fixed-effects model with the generic inverse variance method. Study quality was evaluated using the Newcastle-Ottawa quality assessment scale (NOS). Heterogeneity was evaluated with I 2 statistic. Clinical success, adverse events (AEs) rate, and reintervention rate were the main outcomes. Sensitivity analyses were also conducted. Eight studies including 183 patients were identified. Pooled clinical success was 89% (95% CI, 84%-93%). The pooled clinical success of full-text publication was 88% (95% CI, 83%-93%; I 2 = 0%). Reintervention rate was 8% (95% CI, 4%-12%; I 2 = 0%). The overall AE rate was 10% (95% CI, 6%-15%; I 2 = 0%). The NOS allocated moderate quality in 7 studies. In conclusion, our findings confirm that EUS-GBD in dMBO is a feasible, effective, and safe technique as rescue therapy after failure of ERCP or EUS-BD.

Palliative management for malignant biliary obstruction and gastric outlet obstruction from pancreatic cancer

Pancreatic cancer is among the leading causes of gastrointestinal cancer-related death, with a dismal prognosis. Over 80% of pancreatic cancer patients present with advanced disease, making curative resection unfeasible. These patients are often presented with malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO). In these cases, palliative management is aimed to alleviate symptoms, enhance quality of life, and facilitate subsequent chemotherapy. Currently, neoadjuvant chemotherapy is frequently used in both borderline resectable and resectable pancreatic cancer, necessitating effective biliary and gastrointestinal drainage in a growing number of patients. Traditionally, surgical bypass was the gold standard, performed via either a minimally invasive or open approach. However, notable progress has emerged in developing endoscopic techniques, such as endoscopic retrograde cholangiopancreatography (ERCP) stenting for MBO and endoscopic enteral stenting for GOO. While these procedures provide rapid symptom relief, they are associated with higher stent dysfunction rates and more frequent re-intervention needs. When ERCP fails, percutaneous transhepatic biliary drainage is a widely accepted alternative for MBO. Endoscopic ultrasound (EUS)-guided techniques, including EUS-guided biliary drainage and EUS-guided gastroenterostomy, have recently gained prominence. Emerging clinical data suggest that these methods may be superior, potentially becoming the preferred first-line palliative treatment for unresectable pancreatic cancer. This review will summarize the current evidence on managing MBO and GOO in patients with pancreatic cancer.

Multidisciplinary Therapeutic Approaches to Pancreatic Cancer According to the Resectability Status

Pancreatic ductal adenocarcinoma (PDAC) is among the most lethal cancers, characterized by late diagnosis, rapid progression, and limited therapeutic options. Despite advancements, only 20% of patients are eligible for surgical resection at diagnosis, the sole curative treatment. Multidisciplinary evaluation is critical to optimize care, stratifying patients based on resectability into resectable, borderline resectable, locally advanced, and metastatic stages. Preoperative imaging, such as computed tomography (CT) and endoscopic ultrasound (EUS), remains central for staging, for vascular assessment, and tissue acquisition. Endoscopic and systemic approaches are pivotal for addressing complications like biliary obstruction and improving outcomes. Endoscopic retrograde cholangiopancreatography (ERCP) has been considered for years the gold standard for biliary drainage, although EUS-guided drainage is increasingly utilized due to its efficacy in both resectable and unresectable disease. Systemic therapies play a key role in neoadjuvant, adjuvant, and palliative settings, with ongoing trials exploring their impact on survival and resectability chance. This review highlights the evolving multidisciplinary approaches tailored to the disease stage, focusing on biliary drainage techniques, systemic therapies, and their integration into comprehensive care pathways for PDAC. The continuous refinement of these strategies offers incremental survival benefits and underscores the importance of personalized, multidisciplinary management.

Safety and efficacy of EUS-guided pelvic abscess drainage with lumen-apposing metal stents for complicated acute diverticulitis

BACKGROUND AND AIMS

EUS-guided pelvic abscess drainage (EUS-PAD) with a lumen-apposing metal stent (LAMS) is an alternative approach for postsurgical and inflammatory pelvic collections. This study assessed the safety and efficacy of EUS-PAD with an LAMS in a large population of complicated acute diverticulitis (AD).

METHODS

Data were retrieved on consecutive patients who underwent EUS drainage attempts for complicated AD from 2019 to 2023 in 3 referral centers. All cases have been considered suitable for EUS-PAD after multidisciplinary discussion. Continuous variables are expressed as median (IQR).

RESULTS

Data on 66 patients were retrieved; in 13 cases, EUS-PAD was not indicated because no or small abscess was found. Fifty-three patients (29 female subjects; age, 74 [62-83] years) were finally included. Forty (75.5%) patients had a pelvic abscess, and 13 (24.5%) had a para-colonic abscess, with a median size of 50 (40-60) mm. Transrectal and transcolonic EUS-PAD procedures were performed in 34 (64.2%) and 19 (35.8%) cases, respectively. Technical and clinical success rates were 92.5% and 88.7%; incidence of adverse events was 3.8% (1 bleeding, 1 late migration). LAMSs were removed after 19 (14-28) days. Median follow-up was 12 (8-12) months. Four (7.5%) patients underwent an urgent Hartmann sigmoidectomy, and 12 (22.6%) patients required elective surgery; 2 (3.8%) patients presented with recurrent diverticular abscesses. No procedure-related or disease-specific mortality was observed.

CONCLUSIONS

EUS-PAD could be considered a safe and effective rescue strategy in case of a failed or contraindicated percutaneous approach for the management of complicated AD to reduce the need for urgent surgery. Comparative data are necessary to confirm these observations.

The Role of Therapeutic Endoscopic Ultrasound in Management of Malignant Double Obstruction (Biliary and Gastric Outlet): A Comprehensive Review with Clinical Scenarios

Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life.

Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction: A Comprehensive Review on Technical Tips and Clinical Outcomes

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has dramatically spread and improved in the last two decades and is changing the paradigm of drainage in case of malignant biliary obstruction (MBO). EUS-BD can be achieved from different routes, including the common bile duct (choledochoduodenostomy), intrahepatic bile ducts (hepaticogastrostomy), and gallbladder as a rescue (cholecystogastrostomy/cholecystoduodenostomy). EUS-guided hepaticogastrostomy (EUS-HGS) is a valuable option for biliary drainage in MBO when ERCP fails or is not feasible. EUS-HGS has demonstrated high efficacy with a good rate of technical and clinical success. The safety profile is also overall favorable, although severe adverse events may occur in a significant proportion of patients. From a technical perspective, EUS-HGS is considered one of the most demanding procedures in biliopancreatic endoscopy, requiring multiple steps and high technical skills and experience. In this comprehensive review, technical tips and clinical outcomes of EUS-HGS are reviewed according to the latest evidence in the literature.