Metallic stent deployment in endosonography-guided biliary drainage: long-term follow-up results in patients with bilio-enteric anastomosis

Contemporary advances in the endoscopic management of cholangiocarcinoma: a review of accomplished milestones and prospective opportunities

INTRODUCTION

Cholangiocarcinoma, a primary malignancy of epithelial cells of the bile ducts, has been shown to have increasing incidence rates globally. Many of the current advances aim to improve the accuracy of differentiation between benign biliary strictures and cholangiocarcinoma, which include endoscopic techniques, devices, image processing, and the use of genomic sequencing in acquired specimens.

AREAS COVERED

In this review, the authors explore the historical timeline of changes leading to modern management of cholangiocarcinoma, with special emphasis on endoscopic modalities and novel therapeutic interventions. The authors also expand on the strengths and shortcomings of endoscopic diagnostics and techniques in biliary drainage and finally discuss potential areas to focus for future research and development.

EXPERT OPINION

Despite the advances in diagnosis and management of cholangiocarcinoma, there remain multiple tasks that are still awaiting to be completed. Next-generation sequencing in the diagnosis of cholangiocarcinoma needs to be further tested, validated, and easily obtainable. Other innovative diagnostic modalities, such as the use of artificial intelligence in cholangioscopy, may provide an effective complementary modality to existing techniques. A consensus on biliary drainage needs to be defined and account for longevity and patient convenience.

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.

EUS-Guided Biliary Drainage for Unresectable Malignant Biliary Obstruction: 10-Year Experience of 99 Cases at a Single Center

PURPOSE

To evaluate clinical outcomes of endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) for unresectable malignant biliary obstruction for cases in which endoscopic retrograde cholangiopancreatography (ERCP) failed at a high-volume center.

METHODS

All 99 EUS-BD cases of unresectable malignant biliary obstruction at Sendai City Medical Center between February 2007 and September 2017 were retrospectively evaluated. ERCP is strictly prioritized over EUS-BD during the study period, and EUS-BD was performed in cases wherein ERCP was impossible or ineffective. Technical success, clinical success, adverse events, and time to recurrence of biliary obstruction were evaluated.

RESULTS

EUS-BD was technically successful in 98% of the patients (97/99). The clinical success rate was 93% (90/97). Adverse events that were definitely related to the procedure were observed in ten patients (10%; peritonitis in six, acute cholecystitis in four). Of six patients with bile peritonitis, four suffered from mild localized peritonitis that improved with conservative treatment, whereas two developed pan-peritonitis that improved with additional intervention. Other three patients with a poor performance status succumbed shortly after the successful EUS-BD, with a possible association between the procedure and death. In the 68 patients with a bilioenteric stent, the median time to recurrence of biliary obstruction was 339 days (95% confidence interval (CI), 14-664 days) during the mean follow-up period of 136 ± 173 days.

CONCLUSION

EUS-BD was found to be feasible. However, there were a few patients with an unfavorable course after successful EUS-BD.

Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018

Endoscopic ultrasound/ultrasonography‐guided biliary drainage (EUS‐BD) is a relatively new modality for biliary drainage after failed or difficult transpapillary biliary cannulation. Despite its clinical utility, EUS‐BD can be complicated by severe adverse events such as bleeding, perforation, and peritonitis. The aim of this paper is to provide practice guidelines for safe performance of EUS‐BD as well as safe introduction of the procedure to non‐expert centers. The guidelines comprised patient–intervention–comparison–outcome‐formatted clinical questions (CQs) and questions (Qs), which are background statements to facilitate understanding of the CQs. A literature search was performed using the PubMed and Cochrane Library databases. Statement, evidence level, and strength of recommendation were created according to the GRADE system. Four committees were organized: guideline creation, expert panelist, evaluation, and external evaluation committees. We developed 13 CQs (methods, device selection, supportive treatment, management of adverse events, education and ethics) and six Qs (definition, indication, outcomes and adverse events) with statements, evidence levels, and strengths of recommendation. The guidelines explain the technical aspects, management of adverse events, and ethics of EUS‐BD and its introduction to non‐expert institutions.

Efficacy of a newly developed dilator for endoscopic ultrasound-guided biliary drainage

AIM

To evaluate the efficacy of a newly developed dilator for endoscopic ultrasound (EUS)-guided drainage (ES Dilator).

METHODS

Fourteen consecutive patients who had undergone EUS-guided choledochoduodenostomy (EUS-CDS) with the ES Dilator were identified from a prospectively maintained database and enrolled in the study group. Fourteen other patients who had undergone EUS-CDS without the dilator just prior to its introduction were analyzed as the control group. A historical cohort study was carried out comparing the two groups. The main outcome measurement was the procedure time. The technical success rate and early AE rate were also compared between the two groups.

RESULTS

There were no significant differences in age, sex and etiology of biliary obstruction. The utilization rate of a plastic stent was higher in the control group (36% vs 0%). The technical success rate was 100% in both groups. The mean procedure time was significantly shorter in the study group than in the control group (27 ± 7 min vs 44 ± 26 min, P = 0.026). Additionally, there were no patients who required more than 40 min for the procedure in the study group. Early adverse events occurred in 29% (4/14) of the control group whereas none in the study group. The adverse events in all 4 patients was bile peritonitis, including pan-peritonitis in one patient. All patients recovered with conservative treatment by medication.

CONCLUSION

The newly developed dilator was found to be useful for shortening procedure time and would prevent adverse events related to bile leakage in EUS-CDS.

Endoscopic Ultrasound-Guided Biliary Drainage Using Self-Expandable Metal Stent for Malignant Biliary Obstruction

Purpose. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been increasingly reported worldwide. However, studies concerning EUS-BD from Mainland China are sporadic. This study aims to investigate the feasibility, efficacy, and safety of EUS-BD using SEMS in a single center from Mainland China. Methods. Between November 2011 and August 2015, 24 patients underwent EUS-BD using a standardized algorithm. Results. Three patients underwent rendezvous technique (RV), 4 underwent hepaticogastrostomy (HGS), and 17 underwent choledochoduodenostomy (CDS). The technical and clinical success rates were 95.8% (23/24) and 100% (23/23), respectively. Mean procedure time for the CDS group (35.9 ± 5.0 min) or HGS group (39.3 ± 5.0 min) was significantly shorter than that for the RV group (64.7 ± 9.1 min) (P < 0.05). Complications (13%) included (1) cholangitis and (2) postprocedure hemorrhage. During the follow-up periods (mean 6.4 months), 22 (91.7%) patients died of tumor progression with mean stent patency of 5.8 ± 2.2 months. Stent occlusion occurred in 2 (8.7%) patients. Conclusion. EUS-BD using SEMS is a feasible, effective, and safe alternative for biliary decompression after failed ERCP. EUS-RV may not be the first-line choice for EUS-BD in a medium volume center. Further evaluation and experience of this method are needed.

Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography: Can they be successfully combined?

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.

A Case of Malignant Biliary Obstruction with Severe Obesity Successfully Treated by Endoscopic Ultrasonography-Guided Biliary Drainage

Here, we present a case of malignant biliary tract obstruction with severe obesity, which was successfully treated by endoscopic ultrasonography-guided biliary drainage (EUS-BD). A female patient in her sixties who had been undergoing chemotherapy for unresectable pancreatic head cancer was admitted to our institution for obstructive jaundice. She had diabetes mellitus, and her body mass index was 35.1 kg/m². Initially, endoscopic retrograde cholangiopancreatography (ERCP) was performed, but bile duct cannulation was unsuccessful. Percutaneous transhepatic biliary drainage (PTBD) from the left hepatic biliary tree also failed. Although a second PTBD attempt from the right hepatic lobe was accomplished, biliary tract bleeding followed, and the catheter was dislodged. Consequently, EUS-BD (choledochoduodenostomy), followed by direct metallic stent placement, was performed as a third drainage method. Her postprocedural course was uneventful. Following discharge, she spent the rest of her life at home without recurrent jaundice or readmission. In cases of severe obesity, we consider EUS-BD, rather than PTBD, as the second drainage method of choice for distal malignant biliary obstruction when ERCP fails.

Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review

BACKGROUND AND AIMS

EUS-guided biliary drainage (EUS-BD) has emerged as an alternative procedure after failed ERCP. However, limited data on the efficacy and safety of EUS-BD are available. Therefore, a systematic review was conducted to evaluate the efficacy and safety of EUS-BD and to evaluate transduodenal (TD) and transgastric (TG) approaches.

METHODS

PubMed and EMBASE were searched to identify relevant studies published in the English language for inclusion in this systematic review and meta-analysis. Data from eligible studies were combined to calculate the cumulative technical success rate (TSR), functional success rate (FSR), and adverse-event rate of EUS-BD and the pooled odds ratio of TSR, FSR, and adverse-event rate of the TD approach when compared with the TG approach.

RESULTS

Forty-two studies with 1192 patients were included in this study, and the cumulative TSR, FSR, and adverse-event rate were 94.71%, 91.66%, and 23.32%, respectively. The common adverse events associated with EUS-BD were bleeding (4.03%), bile leakage (4.03%), pneumoperitoneum (3.02%), stent migration (2.68%), cholangitis (2.43%), abdominal pain (1.51%), and peritonitis (1.26%). Ten studies were included in the meta-analysis for comparative evaluation of TD and TG approaches for EUS-BD. Compared with the TG approach, the pooled odds ratio of the TSR, FSR, and adverse-event rate of the TD approach were 1.36 (95% CI, .66-2.81; P > .05), .84 (95% CI, .50-1.42; P > .05), and .61 (95% CI, .36-1.03; P > .05), respectively, which indicated no significant difference in the TSR, FSR, and adverse-event rate between the 2 groups.

CONCLUSIONS

Although it is associated with significant morbidity, EUS-BD is an effective alternative procedure for relieving biliary obstruction. There was no significant difference between the TD and TG approaches for EUS-BD.

Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review

Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.

Uncommon complications of therapeutic endoscopic ultrasonography: What, why, and how to prevent

There is an increasing role for endoscopic ultrasound (EUS)-guided interventions in the treatment of many conditions. Although it has been shown that these types of interventions are effective and safe, they continue to be considered only as alternative treatments in some situations. This is in part due to the occurrence of complications with these techniques, which can occur even when performed by experienced endosonographers. Although common complications have been described for many procedures, it is also crucial to be aware of uncommon complications. This review describes rare complications that have been reported with several EUS-guided interventions. EUS-guided biliary drainage is accepted as an alternative treatment for malignant biliary obstruction. Most of the uncommon complications related to this procedure involve stent malfunction, such as the migration or malposition of stents. Rare complications of EUS-guided pancreatic pseudocyst drainage can result from air embolism and infection. Finally, a range of uncommon complications has been reported for EUS-guided celiac plexus neurolysis, involving neural and vascular injuries that can be fatal. The goal of this review is to identify possible complications and promote an understanding of how they occur in order to increase general awareness of these adverse events with the hope that they can be avoided in the future.

Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review

The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.

Interventional endoscopic ultrasonography

OPINION STATEMENT

Endoscopic ultrasound (EUS) is not only a diagnostic tool but also an interventional and therapeutic procedure. Indeed, in addition to tissue acquisition, it can also drain fluid collections adjacent to the gastrointestinal tract, provide access to biliary and pancreatic ducts, biliary, pancreatic, and gallbladder drainage, pancreatic cyst ablation, and, finally, provide anti-tumoral treatments and interventional vascular procedures. Although several improvements have been made in the last decade, the full potential of interventional EUS is yet to be completely explored. Future areas of research are the development of dedicated tools and accessories, the standardization of the interventional procedures, and the widening of the use of EUS, while increasing the expertise worldwide. In addition, more data, based on well-performed, possibly randomized clinical trials, are needed to accurately determine the risks and long-term outcomes of these interventions. We firmly believe that interventional EUS can play a pivotal role in anti-tumor treatments, by the fine-needle injection of anti-tumoral agents, tumor ablation, and assisting radiation treatment with gold fiducial placement and the implantation of intralesional seeds. The goal of the near future will be to offer targeted therapy and monitoring of tumor treatment response in a more biologically driven manner than has been available in the past. Interventional EUS will be an essential part of the multidisciplinary approach to cancer treatment.