Comparison of the efficacy and safety of endoscopic ultrasound-guided choledochoduodenostomy and hepaticogastrostomy for malignant distal biliary obstruction: Multicenter, randomized, clinical trial

Prevention of Adverse Events in Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is used when biliary drainage using endoscopic retrograde cholangiopancreatography fails. Recently, it has been adopted as a primary biliary drainage method, and its indications have expanded. Since EUS-BD can cause adverse events (AEs), such as bile leakage and stent migration, which do not occur in endoscopic retrograde cholangiopancreatography, endoscopists need to be well-versed in its management and preventive techniques. EUS-BD includes several procedures, such as EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided antegrade stenting (EUS-AS), and EUS-guided rendezvous (EUS-RV). A recent meta-analysis reported that the overall AE rate of EUS-BD was 13.7% (EUS-CDS, 11.9%; EUS-HGS, 15.5%; EUS-AS, 9.9%; and EUS-RV, 8.8%). Among various EUS-BD techniques, EUS-CDS and EUS-HGS are the most frequently reported. Tubular self-expandable metal stents have been traditionally used in EUS-CDS; however, lumen-apposing metal stents have recently gained popularity. A systematic review showed that the rates of early AEs were similar between self-expandable metal stents and lumen-apposing metal stents; however, stent maldeployment was more problematic with lumen-apposing metal stents. Although tubular self-expandable metal stents are used in EUS-HGS, stent maldeployment remains a serious issue, and available devices and technical tips for preventing this AE should be well understood. Furthermore, AEs, such as sepsis, cholangitis, and bleeding, can occur, and strategies to mitigate these risks are essential. In this narrative review, we discussed AEs related to EUS-BD with a focus on management options and strategies for prevention.

Usefulness of a dedicated laser-cut metal stent with an anchoring hook and thin delivery system for EUS-guided hepaticogastrostomy in malignant biliary obstruction: a prospective multicenter trial (with video)

BACKGROUND AND AIMS

EUS-guided hepaticogastrostomy (EUS-HGS) carries a risk of serious adverse events (AEs). A newly designed, partially covered laser-cut stent with antimigration anchoring hooks and a thin tapered tip (7.2F), called a Hook stent (Zeon Medical, Tokyo, Japan), has been developed to prevent serious AEs associated with EUS-HGS. The present prospective multicenter clinical trial evaluated the efficacy and safety of the Hook stent for EUS-HGS after failure of ERCP in patients with unresectable malignant biliary obstruction.

METHODS

The primary endpoint was the rate of clinical success, and secondary endpoints were the rates of technical success, AEs, recurrent biliary obstruction (RBO), procedure success without using a tract dilation device, reintervention for RBO, time to RBO, and overall survival (OS).

RESULTS

Thirty-eight patients underwent EUS-HGS using the Hook stent. The technical and clinical success rates in patients undergoing EUS-HGS were 100% and 92.1%, respectively. The procedure success rate without using a tract dilation device was 94.7%. Four patients (10.5%) developed early AEs, but there were no severe AEs such as stent migration. RBO developed in 26.3% of patients. Reintervention for RBO had a 100% success rate. The median time to RBO was not reached, and the median OS was 191 days.

CONCLUSIONS

EUS-HGS using the Hook stent demonstrated a high clinical success rate, low rate of early AEs, and an acceptable stent patency. The Hook stent is safe and feasible for use in patients undergoing EUS-HGS. (Clinical trial registration number: jRCT2052210020.).

Endoscopic biliary drainage for distal bile duct obstruction due to pancreatic cancer

Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

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.

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.

Quality of Life and Clinical Outcomes of Endosonography-Guided Biliary Drainage in Patients with Malignant Biliary Obstruction: A Single-Center, Prospective Analysis

Introduction: Endosonography-guided biliary drainage (EUS-BD) serves as a rescue treatment modality for patients with malignant biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) fails. Objectives: This study explores the effects of EUS-BD on liver function and quality of life (QoL). Patients and Methods: Patients with malignant biliary obstruction and failed ERCP were enrolled to undergo EUS-BD. QoL, including pruritus severity, was evaluated using EQ-5D-5L and PSS-10 questionnaires before and after EUS-BD. Serum bilirubin and liver function tests were measured on the procedure day, two days, and at least 14 days post-procedure. Results: During a 20-month study period, 1755 ERCPs were performed, with 595 for malignant cases. Of these, 49 underwent EUS-BD following failed ERCP, and 37 (54% women, age range 34-87 years) completed the 14-day follow-up. Pancreatic cancer was the most common (49%) condition, and the median hospital stay was 4 days. Serum bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transferase significantly decreased 2 and 14 days after EUS-BD (all p < 0.001). Pruritus significantly improved, with an average reduction of 5.19 points on the PSS-10 scale two weeks post-procedure (p < 0.001). EUS-BD led to improvements in anxiety and depression according to the EQ-5D-5L (p = 0.013). Conversely, deteriorations were observed in the Mobility, Self-Care, and Usual Activities domains over time (all p < 0.05). Successful EUS-BD enabled the resumption of chemotherapy in 11 (30%) patients. The median post-procedure survival was 112 (range 27-1030) days. Conclusions: EUS-BD improves liver parameters and some aspects of life quality in patients with malignant biliary obstruction, thereby increasing their eligibility for optimal palliative care.

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

BACKGROUND

Malignant Distal Biliary Obstruction (MBDO) is a common event occurring along the natural history of both pancreatic cancer and cholangiocarcinoma. Epidemiological and biological features make MBDO one of the key elements of the clinical management of patients suffering for of pancreatic cancer or cholangiocarcinoma. The development of dedicated biliary lumen-apposing metal stents (LAMS) is changing the clinical work up of patients with MBDO. i-EUS is an Italian network of clinicians and scientists with a special interest in biliopancreatic endoscopy, EUS in particular.

METHODS

The scientific methodology was chosen in line with international guidance and in a fashion similar to those applied by broader scientific associations. PICO questions were elaborated and subsequently voted by a broad panel of experts within a simplified Delphi process.

RESULTS AND CONCLUSIONS

The manuscripts describes the results of a consensus conference organized by i-EUS with the aim of providing an evidence based-guidance for the appropriate use of the techniques in patients with MBDO.

Thin Delivery Stents Can Obviate the Need for Additional Fistula Dilatation of Large Diameter in Endoscopic Ultrasound-Guided Hepaticogastrostomy

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) often requires fistula dilation owing to the placement of a large diameter of the delivery stent. The recently developed delivery devices, which are as thin as 5.9/6.0 Fr, may save the need for fistula dilation. Therefore, we investigated whether large fistula dilation would be required or not in the case of this newly developed thin-diameter delivery stents. Methods: We conducted a retrospective study involving 33 patients implemented with a self-expandable metal stent (SEMS) during EUS-HGS. The patients were categorized based on the delivery device diameter into thin (n = 13; delivery device diameter: 5.9/6.0 Fr) and thick (n = 20; delivery device diameter: 8.5 Fr) groups. We compared the initial rate of success, technical success, and clinical success between the thin and thick groups. The initial rate of success was defined as successful stent placement without a balloon or large diameter mechanical dilation. Results: The rate of the initial stenting success was significantly higher in the thin group (100% [13/13]) compared with that in the thick group (65.0% [13/20]) (p = 0.027). In the thick group, seven cases with technical difficulty in terms of stent placement could be successfully completed with additional fistula dilation with a 9 Fr bougie dilator or 4 mm balloon dilator; this resulted in a technical success of 100% in both groups ultimately. The rate of clinical success was 100% and 95.0% in the thin and thick groups, respectively (p = 1.00). Conclusions: Thin delivery stents may facilitate stent placement without the need for a balloon fistula or large-diameter mechanical dilation.

III BRAZILIAN CONSENSUS STATEMENT ON ENDOSCOPIC ULTRASOUND

BACKGROUND

In the past decades, endoscopic ultrasound has developed from a diagnostic tool to a platform for many therapeutic interventions. Various technological advancements have emerged since the last Brazilian Consensus, demanding a review and update of the recommendations based on the best scientific evidence.

METHODS

A group of 32 renowned echoendoscopists selected eight relevant topics to be discussed to generate clinical questions. After that, a literature review was conducted to answer these questions based on the most updated evidence.

RESULTS

Thirty-three statements were formulated and voted on by the experts to reach a consensus. The Oxford System was used to grade the level of evidence.

CONCLUSION

There is mo-derate evidence to support that the needle shape, gauge, or aspiration technique does not influence the yield of endoscopic ultrasound (EUS)-guided tissue sampling of pancreatic solid lesions. There is moderate evidence to support using EUS-TTNB of the cyst wall to differentiate between mucinous and non-mucinous cystic neoplasms. There is little evidence to support the EUS-guided treatment of gastric varices. There is a high level of evidence to support that EUS-guided biliary drainage and ERCP present similar outcomes in patients with distal malignant biliary obstruction. There is a high level of evidence for using EUS to diagnose neoplastic pancreatic cysts and detect necrosis before indicating drainage. There is moderate evidence to support EUS-GE over duodenal stent for malignant gastric outlet obstruction in patients with a life expectancy higher than 2 months. There is a high level of evidence to support the use of RFA in treating both functioning and non-functioning types of NET.

Efficacy and safety of endoscopic ultrasonography (EUS) hepaticogastrostomy (HGS) versus choledochoduodenostomy (CDS) in ERCP-failed malignant biliary obstruction: A systematic review and META-analysis

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in managing malignant biliary obstruction. The success of ERCP has limitations, whereas surgical biliary bypass and percutaneous transhepatic approaches, as alternative modalities, come with significant costs, longer durations, and higher levels of mortality and morbidity. Endoscopic ultrasonography (EUS)-guided biliary drainage with two approaches, hepaticogastrostomy (EUS-HGS) and choledochoduodenostomy (EUS-CDS), is a favored and evolving alternative modality. This study aims to compare the efficacy and safety of EUS-HGS and EUS-CDS. We conducted a systematic review and meta-analysis by searching PubMed, ScienceDirect, Cochrane Library, and Scholar databases up to August 2023, based on the 2020 PRISMA guidelines. We identified randomized and nonrandomized studies comparing the efficacy and safety of EUS-HGS and EUS-CDS. Outcome measures included technical and clinical success, side effects, and mean procedure time. Nine nonrandomized studies and two randomized controlled trials involving 537 patients (225 EUS-HGS, 312 EUS-CDS) were analyzed. No difference was found in technical success (OR, 0.83; 95% CI, 0.41-1.68; I 2 = 0%) and clinical success between the two procedures (OR, 0.96; 95% CI, 0.51-1.81; I 2 = 9.94%). Side effects were significantly higher in EUS-HGS (OR, 2.01, 95% CI, 1.14-3.59; I 2 = 0%). No significant difference in mean procedure time was observed between the two procedures (0.13; 95% CI, -0.15-0.41; I 2 = 34.89%). There are differences in efficacy and safety between EUS-HGS and EUS-CDS. EUS-CDS has a faster procedure time, lower risk of side effects, and ease of puncture during the procedure.

Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy: a meta-regression analysis

BACKGROUND

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a valid option for EUS-guided biliary drainage that has been increasingly used in the last decade. The aims of this study were to provide a systematic review with meta-analysis and meta-regression of the features and outcomes of this procedure.

METHODS

The MEDLINE, Scopus, Web of Science, and Cochrane databases were searched for literature pertinent to EUS-HGS. Meta-analysis of the proportions and meta-regression of potential modifiers of the main outcome measures were applied. The main outcome was technical success; secondary outcomes were clinical success and procedure-related adverse events (AEs).

RESULTS

33 studies, including 1644 patients, were included in the meta-analysis. Malignant biliary obstruction (MBO) was the underlying cause in almost all cases (99.6%); the main indications for EUS-HGS were duodenal/papillary invasion (34.8%), surgically altered anatomy (18.4%), and hilar stenosis (16.0%). The pooled technical success of EUS-HGS was 97.7% (95%CI 96.1%-99.0%; I 2 = 0%), the intention-to-treat clinical success rate was 88.1% (95%CI 84.7%-91.2%; I 2 = 33.9%), and procedure-related AEs occurred in 12.0% (95%CI 9.8%-14.5%; I 2 = 20.4%), with cholangitis/sepsis (2.8%) and bleeding (2.3%) the most frequent. The rate of procedure-related AEs was lower with the use of dedicated stents on univariable meta-regression analysis. Meta-regression showed that technical success and clinical success rates were modified by the centers' experience (>4/year).

CONCLUSIONS

EUS-HGS represents an effective and safe procedure for EUS-guided biliary drainage in patients with MBO. Future studies should address the impact of center experience, patient selection, and the use of dedicated stents to improve performance of this technique.

Comparison of stent patency between EUS-guided hepaticogastrostomy with bridging and endoscopic transpapillary biliary drainage for hilar obstruction

Background and study aims Endoscopic ultrasound-guided hepaticogastrostomy with bridging between the left and right bile ducts is an alternative to endoscopic transpapillary drainage for malignant hilar biliary obstruction. We aimed to analyze the long-term stent patency of endoscopic ultrasound-guided hepaticogastrostomy with bridging. Patients and methods Patients who underwent endoscopic ultrasound-guided hepaticogastrostomy with bridging between April 2018 and July 2023 were retrospectively analyzed. We retrospectively compared the stent patency of these patients with that of the individuals who underwent endoscopic transpapillary drainage-multi-stenting using unmatched (entire) and propensity score-matched cohorts. Results Endoscopic ultrasound-guided hepaticogastrostomy with bridging had a technical success rate of 90% (18/20). Adverse events were minimal. The number of clinical success cases was 17 and 82 for endoscopic ultrasound-guided hepaticogastrostomy with bridging using metallic stent and endoscopic transpapillary drainage-multi-stenting, respectively. The recurrent biliary obstruction rate was 17.6% and 58.5% for endoscopic ultrasound-guided hepaticogastrostomy with bridging and endoscopic transpapillary drainage-multi-stenting, respectively; the median time to recurrent biliary obstruction (days) was significantly longer for endoscopic ultrasound-guided hepaticogastrostomy with bridging in the entire (not reached vs. 104, P =0.03) and propensity score-matched (183 vs. 79, P =0.05) cohorts. The non-recurrent biliary obstruction rate for endoscopic ultrasound-guided hepaticogastrostomy with bridging was 91.6% at 3 and 6 months and 57% at 12 months. Multivariate analyses revealed that endoscopic ultrasound-guided hepaticogastrostomy with bridging contributed to a lower recurrent biliary obstruction incidence (hazard ratio, 0.31, P =0.05) without significant difference. Conclusions Stent patency was significantly better for endoscopic ultrasound-guided hepaticogastrostomy with bridging. However, future prospective studies are needed.

Efficacy and safety of EUS-guided hepatogastrostomy: A systematic review and meta-analysis

EUS-guided hepaticogastrostomy (EUS-HGS) is one of the preferred methods in biliary drainage where ERCP fails or is contraindicated. The clinical outcomes of EUS-HGS are not well studied because of variability in procedure technique. We conducted a search of multiple electronic databases and conference proceedings from inception through January 2023. The clinical outcomes studied were pooled technical success, clinical success, and adverse events. Standard meta-analysis methods were used using the random-effects model, and heterogeneity was studied by I 2 statistics. We analyzed 44 studies, which included 19 prospective and 25 retrospective studies. The pooled technical success rate of EUS-HGS was 94.4% (confidence interval [CI], 92.4%-95.9%; I 2 = 0%), and the pooled clinical success rate was 88.6% (CI, 83.7%-92.2%; I 2 = 0%). The pooled adverse outcomes with EUS-HGS were 23.8% (CI, 19.6%-28.5%; I 2 = 0%). The mild adverse event rate associated with HGS was 5.8% (4.2%-8.1%; I 2 = 0%), moderate adverse event rate was 12.1% (9.1%-15.8%; I 2 = 16%), and severe adverse event rate was 4.2% (3.0%-5.7%; I 2 = 61%), whereas fatal adverse event rate was 3.2% (1.9%-5.4%; I 2 = 62%). On subgroup analysis, the pooled rate of adverse events of EUS-guided hepaticogastrostomy with antegrade stenting was 13.3% (95% CI, 8.2%-21.0%). The pooled technical success with EUS-guided hepaticogastrostomy with antegrade stenting was 89.7% (95% CI, 82.6%-94.2%), and clinical success was 92.5% (95% CI, 77.9%-97.7%). On the basis of our analysis of EUS-HGS, the overall technical success was 94.4%, and the clinical success rate was 88.6%, and the overall adverse events were reported to be 23.8%. These data can also help improve the clinical benefits of EUS-HGS in the selected patients in whom it is performed.

Endoscopic ultrasound-guided hepaticogastrostomy versus choledochoduodenostomy for malignant biliary obstruction: A meta-analysis

Objectives

Endoscopic ultrasound (EUS)-guided biliary drainage encompasses techniques such as EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy (EUS-CDS). This meta-analysis compared the efficacy of EUS-CDS with that of EUS-HGS for the treatment of biliary obstruction.

Methods

A systematic meta-analysis of all relevant articles listed was performed by searching the Cochrane Library, PubMed, and Google Scholar databases. We used random effects or fixed effects models to compare success rates, adverse events, procedure times, and time to recurrent biliary obstruction after EUS-CDS and EUS-HGS.

Results

This meta-analysis included 18 eligible studies. There was no significant difference between EUS-CDS and EUS-HGS with respect to technical success rate (odds ratio [OR] 1.04; 95% confidence interval [CI] 0.62-1.73) and clinical success rate (OR 0.66; 95% CI 0.43-1.04), or with respect to total procedure-related adverse events (OR 1.39; 95% CI 1.00-1.93). Subgroup analysis of adverse events revealed that the rate of recurrent biliary obstruction (RBO) was significantly higher for EUS-HGS (OR 2.95; 95% CI 1.54-5.64). There was no significant difference between the two methods with respect to time to recurrent biliary obstruction (mean difference -11.93 days; 95% CI -47.77-23.91). However, the procedure time was longer for EUS-HGS (mean difference, 3.21 min; 95% CI 1.24-5.19).

Conclusion

EUS-CDS and EUS-HGS are comparable in terms of technical success, clinical success, and rate of adverse events; however, EUS-CDS is superior with respect to procedure time and preventing RBO.

Comparison of long-term outcomes of endoscopic ultrasound-guided hepaticogastrostomy and choledochoduodenostomy for distal malignant biliary obstruction: a multicenter retrospective study

Background

Endoscopic ultrasound-guided biliary drainage (EUS-BD), classified as choledochoduodenostomy (CDS) and hepaticogastrostomy (HGS), is a feasible and effective alternative for distal malignant biliary obstruction (MBO) in failed endoscopic retrograde cholangiopancreatography. However, the preferred technique for better outcomes has not yet been evaluated.

Objectives

We compared the long-term outcomes between the techniques.

Design

Retrospective comparative study.

Methods

We reviewed consecutive patients who underwent EUS-CDS or EUS-HGS with transmural stent placement for distal MBO between 2009 and 2022. The primary outcome was the stent patency. The secondary outcomes were technical and clinical success, adverse events (AEs) of each technique, and independent risk factors for stent dysfunction.

Results

In all, 115 patients were divided into EUS-CDS (n = 56) and EUS-HGS (n = 59) groups. Among them, technical success was achieved in 98.2% of EUS-CDS and 96.6% of EUS-HGS groups. Furthermore, clinical success was 96.4% in EUS-CDS and 88.1% in EUS-HGS groups, without significant difference (p = 0.200). The mean duration of stent patency for EUS-CDS was 770.3 days while that for EUS-HGS was 164.9 days (p = 0.010). In addition, the only independent risk factor for stent dysfunction was systematic treatment after EUS-BD [hazard ratio and 95% confidence interval 0.238 (0.066-0.863), p = 0.029]. The incidence of stent dysfunction of EUS-HGS was higher than EUS-CDS (35.1% versus 18.2%, 0.071), despite no significant differences even in late AEs.

Conclusion

In distal MBO, EUS-CDS may be better than EUS-HGS with longer stent patency and fewer AEs. Furthermore, systematic treatment after EUS-BD is recommended for the improvement of stent patency.

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.

Biliary drainage in malignant biliary obstruction: an umbrella review of randomized controlled trials

Background

There are still many controversies about biliary drainage in MBO, and we aimed to summarize and evaluate the evidence associated with biliary drainage.

Methods

We conducted an umbrella review of SRoMAs based on RCTs. Through July 28, 2022, Embase, PubMed, WOS, and Cochrane Database were searched. Two reviewers independently screened the studies, extracted the data, and appraised the methodological quality of the included studies. GRADE was used to evaluate the quality of the evidence.

Results

36 SRoMAs were identified. After excluding 24 overlapping studies, 12 SRoMAs, including 76 RCTs, and 124 clinical outcomes for biliary drainage in MBO were included. Of the 124 pieces of evidence evaluated, 13 were rated "High" quality, 38 were rated "Moderate", and the rest were rated "Low" or "Very low". For patients with MBO, 125I seeds+stent can reduce the risk of stent occlusion, RFA+stent can improve the prognosis; compared with PC, SEMS can increase the risk of tumor ingrowth and reduce the occurrence of sludge formation, and the incidence of tumor ingrowth in C-SEMS/PC-SEMS was significantly lower than that in U-SEMS. There was no difference in the success rate of drainage between EUS-BD and ERCP-BD, but the use of EUS-BD can reduce the incidence of stent dysfunction. For patients with obstructive jaundice, PBD does not affect postoperative mortality compared to direct surgery. The use of MS in patients with periampullary cancer during PBD can reduce the risk of re-intervention and stent occlusion compared to PC. In addition, we included four RCTs that showed that when performing EUS-BD on MBO, hepaticogastrostomy has higher technical success rates than choledochoduodenostomy. Patients who received Bilateral-ENBD had a lower additional drainage rate than those who received Unilateral-ENBD.

Conclusions

Our study summarizes a large amount of evidence related to biliary drainage, which helps to reduce the uncertainty in the selection of biliary drainage strategies for MBO patients under different circumstances.

Therapeutic Endoscopic Ultrasound: Current Indications and Future Perspectives

The transcendence of endoscopic ultrasound (EUS) from diagnostic to therapeutic tool has revolutionized management options in the field of gastroenterology. Through EUS-guided methods, pancreaticobiliary obstruction can now be utilized as an alternative to surgical and percutaneous approaches. This modality also allows for gallbladder drainage in patients who are not ideal operative candidates. By utilizing its unique imaging capabilities, EUS also allows for drainage access points in cases of gastric outlet obstruction as well as windows to ablate pancreatic cystic lesions. As technical progress continues to evolve, interventional gastroenterology continues to push the envelope of minimally invasive therapeutic procedures in a multidisciplinary setting. In this comprehensive review, we set out to describe current indications and innovations through EUS.

Prospective clinical trial of EUS-guided choledochoduodenostomy without fistula dilation for malignant distal biliary obstruction

Background and Objectives

During EUS-guided choledochoduodenostomy (EUS-CDS), fistula dilation before stent insertion is associated with adverse events (AEs), such as bile leakage and peritonitis. We hypothesized that EUS-CDS without fistula dilation using a novel self-expandable metal stent (SEMS) with a thin delivery system could overcome this problem, and we conducted this study to evaluate its feasibility and safety.

Methods

This was an open-label, single-arm, phase II study at a single institution. We planned EUS-CDS without fistula dilation using a fully covered SEMS with a 5.9-Fr delivery system for unresectable malignant distal biliary obstruction. The primary outcome was overall technical success. Secondary outcomes were technical success without fistula dilation, procedure time, functional success, time to recurrent biliary obstruction, and AEs. The planned sample size was 25 patients.

Results

In total, 24 patients were included in this study. In 21 patients, EUS-CDS was performed as primary drainage. The overall technical success rate was 100% (24 of 24 patients). The technical success rate without fistula dilation was 96% (23 of 24). The median procedure time was 16 min (range, 10-66 min). The functional success rate was 96% (23 of 24). The median time to recurrent biliary obstruction was 148 days (95% confidence interval, 29-266 days). There were no procedure-related AEs. Furthermore, computed tomography immediately after the procedure showed no leakage of contrast medium into the abdominal cavity in any patient.

Conclusions

EUS-guided choledochoduodenostomy without fistula dilation using a fully covered SEMS with a 5.9-Fr delivery system is feasible with a high probability and can be achieved quickly while effectively preventing bile leakage and peritonitis.

Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage

Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.

Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are currently first- and second-line therapeutic options, respectively, for the relief of biliary obstruction. In recent years, however, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an established alternative therapy for biliary obstruction. There are multiple different techniques for EUS-BD, which can be distinguished based on the access point within the biliary tree (intrahepatic versus extrahepatic) and the location of stent placement (transenteric versus transpapillary). The clinical and technical success rates of biliary drainage for EUS-BD are similar to both ERCP and PTBD, and complication rates are favorable for EUS-BD relative to PTBD. As EUS-BD becomes more widely practiced and endoscopic tools continue to advance, the outcomes will likely improve, and the breadth of indications for EUS-BD will continue to expand.

Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part I (Indications, Outcomes, Comparative Evaluations, Training)

Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates.

EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized.

Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Comparison of recurrent biliary obstruction with the use of metal and plastic stents in EUS-guided biliary drainage: A propensity score-matched analysis

Background and Objectives

In transpapillary biliary drainage, metal stents (MSs) exhibit a lower incidence of a biliary obstruction than plastic stents (PSs). However, few studies have compared recurrent biliary obstruction (RBO) when MSs and PSs are used in EUS-guided hepaticogastrostomy (EUS-HGS) and choledochoduodenostomy (EUS-CDS). We retrospectively evaluated the RBO for both stents in each procedure.

Patients and Methods

: Between November 2012 and December 2020, 85 and 53 patients who underwent EUS-HGS and EUS-CDS for unresectable malignant biliary obstruction, respectively, were enrolled. Factors associated with RBO were assessed. Clinical outcomes were compared between the MS and PS groups using propensity score matching.

Results

: The clinical success rate and procedure-related adverse events were similar in the MS and PS groups. Multivariate analysis identified the use of PS as a factor associated with RBO (EUS-HGS, P = 0.03; EUS-CDS, P = 0.02). After matching, the median time to RBO in EUS-HGS (MS: 313; PS: 125 days; P = 0.01) in the MS group was longer than that in the PS group. The cumulative incidence of RBO at 1, 3, and 6 months in the MS group was significantly lower than that in the PS group for EUS-HGS (MS: 4.0%, 8.2%, and 8.2%; PS: 12.4%, 24.9%, and 39.5%, respectively, P = 0.01).

Conclusions

: MS exhibited a lower rate of RBO than PS for EUS-HGS and EUS-CDS.

Feasibility and efficacy of endoscopic reintervention after covered metal stent placement for EUS-guided hepaticogastrostomy: A multicenter experience

Background and Objectives

Although the use of a long metal stent is favored for EUS-guided hepaticogastrostomy (EUS-HGS) for the relief of malignant biliary obstruction (MBO), endoscopic reintervention (E-RI) at the time of recurrent biliary obstruction (RBO) is challenging due to a long intragastric portion. This study evaluated the feasibility and safety of E-RI after a long partially covered metal stent (L-PCMS) placement during EUS-HGS.

Materials and Methods

We performed a multicenter retrospective study between January 2015 and December 2019 examining patients with MBO who underwent E-RI for RBO through the EUS-HGS route after the L-PCMS placement. Technical and clinical success rates, details of E-RI, adverse events (AEs), stent patency, and survival time were evaluated.

Results

Thirty-three patients at eight referral centers in Japan who underwent E-RI through the EUS-HGS route were enrolled. The location of MBO was distal in 54.5%. The median intragastric length of the L-PCMS was 5 cm. As the first E-RI attempt, E-RI via the distal end of the existing L-PCMS was successful in 60.6%. The overall technical and clinical success rates of E-RI were 100% and 81.8%, respectively. Liver abscess was noted in one patient. A proximal biliary stricture was associated with the clinical ineffectiveness of E-RI in multivariable analysis (odds ratio, 12.5, P = 0.04). The median survival and stent patency duration after E-RI were 140 and 394 days, respectively.

Conclusions

Our study findings suggest that E-RI for RBO after EUS-HGS with a L-PCMS is technically feasible and clinically effective, without any severe AEs, especially for patients with distal MBO.

Long-term outcomes and predictors of adverse events of EUS-guided hepatico-gastrostomy for malignant biliary obstruction: Multicenter, retrospective study

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) may be a feasible and useful alternative in patients with malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). To date, the risk factors for adverse events (AEs) and long-term outcomes of EUS-HGS have not been fully explored according to stent type. Therefore, we evaluated potential risk factors for AEs and long-term outcomes of EUS-HGS.

METHODS

In total, 120 patients who underwent EUS-HGS were retrospectively reviewed. A multivariate analysis through Cox proportional hazard and logistic regression model was used to identify the risk factors for stent dysfunction and AEs, respectively. Stent patency and patient survival were evaluated using Kaplan-Meier plots with a log-rank test for each stent.

RESULTS

The technical and clinical success rates were 96.2% (102/106) and 83.0% (88/106). The median duration of stent patency was longer in self-expandable metal stents (SEMS) compared to plastic stents (PS) (158 vs. 108 days). Kaplan-Meier analysis indicated that the type of stent was not associated with stent patency (Hazard ratios [HR] 0.997, 95% confidence interval [CI] [0.525-1.896]) or overall survival. In addition, multivariate analysis indicated that hilar MBO significantly associated with stent dysfunction (HR, 2.340; 95% CI, 1.028-5.326, p = 0.043) and late AEs.

CONCLUSIONS

Given the lower incidence of AEs and better long-term outcomes of EUS-HGS, it can be considered a safe alternative to ERCP or percutaneous approaches regardless of which stent is used. Furthermore, hilar MBO was established as a potential risk factor for stent dysfunction and late AEs.

Introduction of endoscopic ultrasound-guided hepaticoenterostomy - experience from a general hospital in Japan

Background and study aims Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a widely used alternative to endoscopic retrograde cholangiopancreatography (ERCP) when ERCP is unsuccessful or there are contraindications such as duodenal stenosis or postsurgical intestinal reconstruction. Therefore, we retrospectively investigated the therapeutic outcomes of EUS-BD in a medium-sized hospital.

Patients and methods We included 31 consecutive patients who underwent EUS-BD at the Kitasato University Medical Center between April 2018 and October 2021. Patient characteristics, technical and clinical success rates, stent patency, adverse events (AEs), and procedure time were analyzed.

Results Of the 31 patients included in this study, one underwent endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and 30 underwent endoscopic ultrasound-guided hepaticoenterostomy (EUS-HES). The technical success rates were 100 % for EUS-CDS and 96.8 % for EUS-HES because EUS-HES was unsuccessful in one patient who then underwent EUS-CDS as an alternative treatment. The clinical success rates were 100 % for EUS-CDS and 96.7% for EUS-HES. The median follow-up period was 84 days (range: 14–483 days). Zero and 5 (16.6 %) patients who underwent EUS-CDS and EUS, respectively had stent dysfunction. The median stent patency (stent dysfunction and death) for EUS-HES was 124 days. AEs were observed in only two patients (6.7 %) who underwent EUS-HES.

Conclusions EUS-BD is now more widely used than before, and advances in the devices used have enabled the procedure to be performed more safely. Our results suggest that this introduction in medium-sized hospitals can be conducted safely.

Endoscopic palliation of malignant biliary obstruction

Malignant biliary obstruction often presents with challenges requiring the endoscopist to assess the location of the lesion, the staging of the disease, the eventual resectability and patient preferences in term of biliary decompression. This review will focus on the different modalities available in order to offer the most appropriate palliation, such as conventional endoscopic retrograde cholangiopancreatography, endoscopic ultrasound guided biliary drainage as well as ablative therapies including photodynamic therapy or radiofrequency ablation.

Utility of Fine-Gauge Balloon Catheter for EUS-Guided Hepaticogastrostomy

Background and Purpose: During endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), tract dilation is one of the most important steps, and the placement of conventional metal stents with 8.5 Fr delivery devices is difficult due to the large outer shape of the device. Fine-gauge balloon catheters have become popular because of their stricture penetration ability and ease of dilation. This study aimed to evaluate the utility of fine-gauge balloon catheters. Patients and Methods: This retrospective study involved 38 patients who underwent conventional metal stent placement. The patients were classified into two groups: those who underwent dilation with a fine-gauge balloon catheter before initial metal stenting (balloon dilation group) and those who underwent bougie dilation only (non-balloon dilation group). We evaluated the stenting success rate after initial dilation and adverse events. Results: Seventeen and twenty-one patients were included in the balloon dilation and non-balloon dilation groups, respectively. The stenting success rate after initial dilation was 100% (17/17) in the balloon dilation group and 71.4% (15/21) in the non-balloon dilation group (p = 0.024). As adverse events, peritonitis was observed in one case (4.8%) in the balloon dilation group, and in three cases (14.3%) in the non-balloon dilation group (p = 0.613). Conclusions: Dilation using a fine-gauge balloon catheter before conventional metal stent with 8.5 Fr delivery device placement is considered effective in EUS-HGS.

Current endoscopic approaches to biliary strictures

PURPOSE OF REVIEW

To summarize the current status and future perspectives of the endoscopic management of biliary strictures.

RECENT FINDINGS

In addition to conventional diagnostic modalities, such as cross-sectional imaging and endoscopic ultrasonography (EUS), per-oral cholangioscopy is helpful for indeterminate biliary strictures. It allows direct visualization of the biliary tract and targeted biopsy. For distal malignant biliary obstruction (MBO), a self-expandable metal stent (SEMS) via endoscopic retrograde cholangiopancreatography (ERCP) is a standard of care. EUS-guided biliary drainage (EUS-BD) is an emerging alternative to percutaneous transhepatic biliary drainage in cases with failed ERCP. EUS-BD is also an effective salvage option for perihilar MBO, which can not be managed via ERCP or percutaneous transhepatic biliary drainage. Preoperative drainage is necessary for most jaundiced patients as neoadjuvant chemotherapy is widely administered for resectable and borderline resectable pancreatic cancer, and a SEMS is preferred in this setting, too. For benign biliary strictures, a covered SEMS can improve stricture resolution and reduce the number of endoscopic sessions as compared to plastic stents.

SUMMARY

ERCP and EUS play a central role in the diagnosis and drainage for both malignant and benign biliary strictures.

Endoscopic ultrasound guided biliary interventions

Endoscopic Retrograde Cholangiopancreatography (ERCP), even in expert hands, may fail in 5-10% of cases, especially in cases of papillary infiltration, malignant gastric outlet obstruction, or surgically altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has represented the traditional rescue therapy, despite associated with high rate of adverse events, need for re-interventions and an inferior quality of life. The evolution of Endoscopic Ultrasound (EUS) from a diagnostic to a therapeutic tool offers an effective and safe alternative for internal biliary drainage (BD) into the stomach or the duodenum. EUS-BD is reported to have similar or even improved efficacy and increased safety when compared to PTBD and can be performed in the same session of a failed ERCP. This review summarizes technical aspects of intra-hepatic and extra-hepatic EUS-BD (including hepatico-gastrostomy, choledocho-duodenostomy and rendezvous) together with current evidence and future perspectives that steadily cements EUS-BD's place in multidisciplinary management of bilio-pancreatic diseases.

How to perform EUS-guided biliary drainage

EUS-guided biliary drainage (EUS-BD) has recently gained widespread acceptance as a minimally invasive alternative method for biliary drainage. Even in experienced endoscopy centers, ERCP may fail due to inaccessibility of the papillary region, altered anatomy (particularly postsurgical alterations), papillary obstruction, or neoplastic gastric outlet obstruction. Biliary cannulation fails at first attempt in 5%-10% of cases even in the absence of these factors. In such cases, alternative options for biliary drainage must be provided since biliary obstruction is responsible for poor quality of life and even reduced survival, particularly due to septic cholangitis. The standard of care in many centers remains percutaneous transhepatic biliary drainage (PTBD). However, despite the high technical success rate with experienced operators, the percutaneous approach is more invasive and associated with poor quality of life. PTBD may result in long-term external catheters for biliary drainage and carry the risk of serious adverse events (SAEs) in up to 10% of patients, including bile leaks, hemorrhage, and sepsis. PTBD following a failed ERCP also requires scheduling a second procedure, resulting in prolonged hospital stay and additional costs. EUS-BD may overcome many of these limitations and offer some distinct advantages in accessing the biliary tree. Current data suggest that EUS-BD is safe and effective when performed by experts, although SAEs have been also reported. Despite the high number of clinical reports and case series, high-quality comparative studies are still lacking. The purpose of this article is to report on the current status of this procedure and to discuss the tools and techniques for EUS-BD in different clinical scenarios.

Safe Performance of Track Dilation and Bile Aspiration with ERCP Catheter in EUS-Guided Hepaticogastrostomy with Plastic Stents: A Retrospective Multicenter Study

Objectives: Endoscopic-ultrasound-guided hepaticogastrostomy (EUS-HGS) with plastic stent placement is associated with a high incidence of adverse events that may be reduced using an endoscopic retrograde cholangiopancreatography (ERCP) contrast catheter in the track dilation step. In this study, we evaluated the usefulness of track dilation and bile aspiration performed with an ERCP contrast catheter in EUS-HGS with plastic stent placement. Methods: In a multicenter setting, 22 EUS-HGS cases dilated with an ERCP contrast catheter were analyzed retrospectively and compared between a bile aspiration group and no bile aspiration group. Results: Overall, adverse events occurred in three (13.6%) cases of bile leakage, three (13.6%) cases of peritonitis, and one (4.5%) case of bleeding. Comparing patients with and without bile aspiration, 6 of the 11 patients (54.5%) with no bile aspiration had adverse events, whereas only 1 of the 11 patients (9.1%) who had bile aspiration, as much bile as possible, had an adverse event (bleeding). In univariate analysis, the only factor affecting the occurrence of adverse events was bile aspiration whenever possible (odds ratio, 12.0; 95%CI 1.12–128.84). Conclusions: In EUS-HGS with plastic stent placement, track dilation and bile aspiration with an ERCP contrast catheter may be useful in reducing adverse events.

Methods for Drainage of Distal Malignant Biliary Obstruction after ERCP Failure: A Systematic Review and Network Meta-Analysis

There is scarce evidence on the comparison between different methods for the drainage of distal malignant biliary obstruction (DMBO) after endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we performed a network meta-analysis to compare the outcomes of these techniques. We searched main databases through September 2021 and identified five randomized controlled trials. The primary outcome was clinical success. The secondary outcomes were technical success, overall and serious adverse event rate. Percutaneous trans-hepatic biliary drainage was found to be inferior to other interventions (PTBD: RR 1.01, 0.88-1.17 with EUS-choledochoduodenostomy (EUS-CD); RR 1.03, 0.86-1.22 with EUS-hepaticogastrostomy (EUS-HG); RR 1.42, 0.90-2.24 with surgical hepaticojejunostomy). The comparison between EUS-HG and EUS-CD was not significant (RR 1.01, 0.87-1.17). Surgery was not superior to other interventions (RR 1.40, 0.91-2.13 with EUS-CD and RR 1.38, 0.88-2.16 with EUS-HG). No difference in any of the comparisons concerning adverse event rate was detected, although PTBD showed a slightly poorer performance on ranking analysis (SUCRA score 0.13). In conclusion, all interventions seem to be effective for the drainage of DMBO, although PTBD showed a trend towards higher rates of adverse events.

Endoscopic Ultrasound-Guided Biliary Interventions

Endoscopic ultrasound (EUS)-guided biliary interventions have evolved to become an integral part of advanced gastrointestinal endoscopy units. EUS-guided biliary drainage is an accepted alternative for patients with failed ERCP or altered surgical anatomy. The potential advantages of EUS-guided interventions include choice of biliary access from stomach or duodenum, choice of stent exit in stomach and duodenum, and possibility of avoiding traversing through the obstruction. A variety of procedures have been described depending on the level of obstruction. Maximum evidence is available for distal malignant obstruction, and more studies are needed for hilar obstruction and benign indications.

Investigator initiated clinical trial to validate usefulness of specific system for endoscopic ultrasound guided hepaticogastrostomy (HG01) in malignant biliary obstruction (HG01)

INTRODUCTION

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a novel drainage option for patients with an inaccessible papilla. Although EUS-HGS has clinical benefits in patients for whom endoscopic retrograde cholangiopancreatography (ERCP) has failed, the rates of adverse events (AEs) associated with EUS-HGS, such as bile peritonitis and stent migration, are higher than for other procedures. The development of a dedicated system for EUS-HGS is therefore desirable to reduce the rate of AEs. We developed a dedicated system for EUS-HGS (HG01 system) which is composed of a 19-gauge needle, 0.025-inch guidewire, a thin delivery system for tract dilation, and an antimigration metal stent. This study is designed to evaluate the efficacy and safety of EUS-HGS using the HG01 system in malignant biliary obstruction.

METHODS/DESIGN

This is a single-arm multicenter prospective study involving 40 patients across six tertiary centers in Japan. Patients with an unresectable malignant biliary obstruction in whom biliary drainage with ERCP failed, is not possible, or is very difficult will be registered in the study. The primary endpoint is the clinical success rate. The secondary endpoints are the technical success rate, procedure-related AE rate, procedure time, procedure success rate using only the HG01 system, stent patency rate, re-intervention success rate, re-intervention method, survival rate, and distance of movement of the stent position.

DISCUSSION

We expect use of the HG01 system to reduce the rate of AEs during EUS-HGS, especially bile leakage and stent migration. If the efficacy and safety of EUS-HGS using the HG01 system is confirmed in the present study, it is likely to be considered the first-choice device for use during EUS-HGS.

Relief of jaundice in malignant biliary obstruction: When should we consider endoscopic ultrasonography-guided hepaticogastrostomy as an option?

BACKGROUND

Since it was first described in 2001, endoscopic ultrasonography-guided biliary drainage (EUS-BD) has emerged as an alternative procedure for achieving an endoscopic internal drainage in case of endoscopic retrograde cholangiopancreatography (ERCP) failure. Biliary drainage can be achieved by either a transduodenal extrahepatic approach through EUS-guided choledochoduodenostomy (EUS-CDS), or a transgastric intrahepatic approach, namely EUS-guided hepaticogastrostomy (EUS-HGS) which already holds a remarkable place in the treatment of patients with malignant biliary obstruction.

DATA SOURCES

For this review we did a comprehensive search of PubMed/MEDLINE from inception to May 31, 2021 for papers with a significant sample size (at least 20 patients enrolled) dealing with EUS-HGS. Data on technical success, clinical success and rate of adverse events were collected.

RESULTS

A total of 22 studies with different design, comprising 874 patients, were included. Technical success was achieved in about 96% of cases (ranging from 65% to 100%). Clinical success was obtained in almost 91% of cases (ranging from 76% to 100%). Overall rate of adverse events was 19% (ranging from 0% to 35%). Abdominal pain, self-limiting pneumoperitoneum, bile leak, cholangitis, bleeding, perforation and intraperitoneal migration of the stent were the most common.

CONCLUSIONS

Despite both safety and efficacy profile, at the moment HGS still remains a challenging procedure at every single step and must therefore be conducted by a very experienced endoscopist in interventional EUS and ERCP procedures, who is able to deal with the possible severe adverse events of this procedure. A rapid introduction in clinical practice of dedicated devices is desiderable.

Usefulness of the laser-cut fully covered self-expandable metallic stent for endoscopic ultrasound-guided hepaticogastrostomy

BACKGROUND/PURPOSE

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has many associated adverse events. We evaluated the clinical efficacy and safety of the laser-cut fully covered self-expandable metallic stent (FCSEMS) for this procedure.

METHODS

This single-center, retrospective study included cases where EUS-HGS with a laser-cut FCSEMS was performed for malignant biliary obstruction. Technical and clinical success, time to recurrent biliary obstruction (TRBO), procedure time, adverse events, and re-interventions were evaluated.

RESULTS

There were 95 eligible cases. Technical and clinical success rates were 100.0% and 95.8%, respectively. Median TRBO was 398 days. RBO causes were hyperplasia (7.4%), debris (3.2%), and migration (4.2%). Adverse events occurred in nine cases (9.5%). Non-occlusion and focal cholangitis occurred in four cases (4.2%) each. Nineteen patients (20%) underwent combined EUS-HGS (CH) procedures: antegrade stenting, bridging methods, plastic stent anchoring in SEMS, and EUS-hepaticoduodenostomy. The solely EUS-HGS (SH) group had significantly longer median TRBO than the CH group (398 vs. 246 days; P=0.04). There were no significant differences in adverse events between the two groups. Re-intervention was performed in 29 cases (technical success rate: 100.0%).

CONCLUSIONS

Laser-cut FCSEMS can be safely placed in the bile duct and easily applied during re-intervention, making it useful in EUS-HGS.

When ERCP Fails: EUS-Guided Access to Biliary and Pancreatic Ducts

Pancreaticobiliary (PB) endotherapy continues to progress in the era of therapeutic endosonography. Endoscopic retrograde cholangiopancreatography (ERCP) remains the primary method for PB access in native and altered anatomy. In altered anatomy, PB access can be obtained via enteroscopy-assisted ERCP (e-ERCP) or laparoscopy-assisted ERCP; however, both approaches have significant limitations. Endoscopic ultrasound-guided biliary and pancreatic duct drainage (EUS-BPD) are increasingly becoming the preferred alternative when ERCP fails, with advantages over percutaneous drainage. EUS-BPD continues to evolve with better feasibility, safety and efficacy as dedicated procedural equipment continues to improve. In this article, we discuss the role of endoscopic ultrasound (EUS) when ERCP fails and their indications, technique, and outcomes.

Practical Tips for Safe and Successful Endoscopic Ultrasound-Guided Hepaticogastrostomy: A State-of-the-Art Technical Review

Currently, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is widely performed worldwide for various benign and malignant biliary diseases in cases of difficult or unsuccessful endoscopic transpapillary cholangiopancreatography (ERCP). Furthermore, its applicability as primary drainage has also been reported. Although recent advances in EUS systems and equipment have made EUS-HGS easier and safer, the risk of serious adverse events such as bile leak and stent migration still exists. Physicians and assistants need not only sufficient skills and experience in ERCP-related procedures and basic EUS-related procedures such as fine needle aspiration and pancreatic fluid collection drainage, but also knowledge and techniques specific to EUS-HGS. This technical review mainly focuses on EUS-HGS with self-expandable metal stents for unresectable malignant biliary obstruction and presents the latest and detailed tips for safe and successful performance of the technique.

Comparison of Choledochoduodenostomy and Hepaticogastrostomy for EUS-Guided Biliary Drainage: A Meta-Analysis

Background

Although endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) or hepaticogastrostomy (EUS-HGS) has emerged as an option for patients of failed endoscopic retrograde cholangiopancreatography (ERCP), there has no agreement on which approach is preferred. Therefore, a meta-analysis was performed to examine the two methods.

Methods

We performed a comprehensive search in databases of PubMed, Embase, and Cochrane library to find relevant studies reporting the efficacy and safety of the two EUS-guided biliary drainage methods.

Results

In total, 12 studies with 623 patients (EUS-CDS: 303 and EUS-HGS: 320) were included. The cumulative technical success and clinical success for EUS-CDS and EUS-HGS was 95.0% (288/303), 93.1% (268/288), and 96.6% (309/320), 91.3% (282/309), respectively. Compared with EUS-HGS, the pooled odds ratio (OR) was 0.74 (95% CI 0.33–1.65; p = 0.46) for EUS-CDS technical success and 0.94 (95% CI 0.56–1.59; p = 0.83) for clinical success. The pooled difference in means of procedure time of EUS-CDS and EUS-HGS was −2.68 (95% CI −5.12 to −0.24; p = 0.03). The cumulative early adverse events for EUS-CDS and EUS-HGS was 12.2% (37/303) and 17.5% (56/320), respectively. Compared with EUS-HGS, the pooled OR of early adverse events for EUS-CDS was 0.58 (95% CI: 0.36–0.93; p = 0.02).

Conclusion

This meta-analysis further suggests EUS-CDS and EUS-HGS have equal high technical and clinical success, but EUS-CDS with a slightly short procedure time and with less early adverse events compared to EUS-HGS.

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.

Endoscopic ultrasound-guided gallbladder and bile duct drainage with lumen apposing metal stent: A large multicenter cohort (with videos)

BACKGROUND AND AIM

Cholecystectomy and endoscopic retrograde cholangiopancreatography are the gold standard for managing acute cholecystitis and malignant biliary obstruction, respectively. Recent advances in therapeutic endoscopic ultrasound (EUS) have provided alternatives for managing patients in whom these approaches fail, namely, EUS-guided gallbladder drainage (EUS-GB) and EUS-guided bile duct drainage (EUS-BD). We aimed to assess the technical and clinical success of these techniques in the largest multicenter cohort published to date.

METHODS

A retrospective, multicenter, observational study involving 17 centers across Australia and New Zealand was conducted. All patients who had EUS-GB or EUS-BD performed in a participating center using a lumen apposing metal stent between 2016 and 2020 were included. Primary outcome was technical success, defined as intra-procedural successful drainage. Secondary outcomes included clinical success and 30-day mortality.

RESULTS

One hundred and fifteen patients underwent EUS-GB (n = 49) or EUS-BD (n = 66). EUS-GB was technically successful in 47 (95.9%) while EUS-BD was successful in 60 (90.9%). All failed cases were due to maldeployment of the distal flange outside of the targeted lumen. Clinical success of EUS-GB was achieved in 39 (79.6%). No patients required subsequent cholecystectomy. Clinical success of EUS-BD was achieved in 52 (78.8 %). Thirty-day mortality was 14.3% for EUS-GB and 12.1% for EUS-BD.

CONCLUSIONS

EUS-guided gallbladder drainage and EUS-BD are promising alternatives for managing nonsurgical candidates with cholecystitis and malignant biliary obstruction following failed endoscopic retrograde pancreatography. Both techniques delivered high technical success with acceptable clinical success. Further research is needed to investigate the gap between technical and clinical success.

Efficacy of lumen-apposing metal stents or self-expandable metal stents for endoscopic ultrasound-guided choledochoduodenostomy: a systematic review and meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided biliary drainage is becoming an option for palliation of malignant biliary obstruction. Lumen-apposing metal stents (LAMS) are replacing self-expandable metal stents (SEMS). The aim of this meta-analysis was to evaluate the efficacy and safety of LAMS and SEMS for EUS-guided choledochoduodenostomy (EUS-CDS).

METHODS

A meta-analysis was performed using PRISMA protocols. Electronic databases were searched for studies on EUS-CDS. The primary outcome was clinical success. Secondary outcomes were technical success, reintervention, and adverse events. We used the random effects model with the DerSimonian-Laird estimation, and the results were depicted using forest plots. Subgroup analyses were also performed with data stratified by selected variable.

RESULTS

Overall, 31 studies (820 patients) were included. The pooled rates of clinical and technical success were 93.6 % (95 % confidence interval [CI] 88.6 %-96.5 %) and 94.8 % (95 %CI 90.2 %-97.3 %) for LAMS, and 91.7 % (95 %CI 88.1 %-94.2 %) and 92.7 % (95 %CI 89.9 %-94.9 %) for SEMS, respectively. The pooled rates of adverse events were 17.1 % (95 %CI 12.5 %-22.8 %) for LAMS and 18.3 % (95 %CI 14.3 %-23.0 %) for SEMS. The pooled rates of reintervention were 10.9 % (95 %CI 7.7 %-15.3 %) for LAMS and 13.9 % (95 %CI 9.6 %-19.7 %) for SEMS. Subgroup analyses confirmed these results.

CONCLUSIONS

This meta-analysis showed that LAMS and SEMS are comparable in terms of efficacy for EUS-CDS. Clinical and technical success, post-procedure adverse events, and reintervention rates were similar between LAMS and SEMS use; however, adverse events require further investigation.