Introduction

EUS-guided gall bladder drainage (EUS-GBD) with an electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) is emerging as a method of establishing gall bladder drainage in patients who lack fitness for surgery¹.
The aim of the study was to assess the efficacy, safety and long-term outcomes in patients who underwent EUS-GBD with an EC-LAMS.

Aims & Methods

A retrospective review of consecutive patients who underwent EUS-GBD with EC-LAMS at 11 tertiary institutions across the United Kingdom and Ireland between January 2016 and December 2022 was undertaken.

Results

Sixty two patients (71.0% female; n=44) with a median age of 74.6 years (range 33-95 years) were included. The predominant approach was transduodenal (59.7%; n=37), while the most common indication was non-malignant cholecystitis (56.5%; n=35).
The mean follow-up period was 2.1 years (range 0.04-6.9 years); 72.6% (n=45) were alive at the end of the follow-up period.
Technical success, defined as successful gall bladder access followed by adequate transmural EC-LAMS deployment, was achieved in 95.2% (n=59). Clinical success, defined as resolution of clinical parameters of acute cholecystitis (as per Tokyo 2018 diagnostic criteria) within 96 hours was achieved in 94.7% (n=54).
The 30-day adverse event rate was 4.8% (n=3), with 3.2% (n=2) experiencing a severe/fatal event (as per ASGE lexicon). A further adverse event (1 severe) occurred in 14.8% (n=4) of those who were followed up for a year and in 7.1% (n=1) of those who were followed up for two years.
Of those with benign disease, the EC-LAMS was removed in 15.0% (n=3) of cases who were followed up for at least one year. This was associated with an adverse event (recurrent cholecystitis) in only one case.

Conclusion

EUS-GBD with EC-LAMS at tertiary institutions is a highly effective and relatively safe technique in patients who are not fit for surgery. Technical failures or adverse events can usually be managed conservatively or with endoscopic therapy.

References

References:

1. Luo X, Sharaiha R, Teoh AYB. Endoscopic Management of Acute Cholecystitis. Gastrointest Endosc Clin N Am. 2022 Jul;32(3):527-543.

Introduction

Endoscopic intermuscular dissection (EID) was recently introduced as a novel resection technique for deep submucosal invasive rectal cancer (D-SMIC)¹. While short-term outcomes are promising, intermediate- and long-term oncological safety has not yet been established. Therefore, we aimed to evaluate the 3-year oncological outcomes of EID for suspected rectal D-SMIC.

Aims & Methods

In this prospective cohort study, data of consecutive patients treated with EID for suspected rectal D-SMIC at two academic hospitals in the Netherlands between 2018 and 2022 were analyzed. Superficial submucosal invasive cancer (S-SMIC) was defined as Sm1 and D-SMIC as Sm2-3. Tumors were considered high-risk if they exhibited at least one of the following histological risk factors: high-grade tumor differentiation (G3), lymphovascular invasion, tumor budding grade 2-3, R1/Rx resection margins (<0.1 mm), or ≥pT2 invasion. Patients with D-SMIC or ≥pT2 invasion who did not undergo further treatment after EID, either due to the absence of additional risk factors or based on patient preference, underwent close surveillance. This surveillance involved biannual MRI and endoscopic scar inspection for 2 years, followed by annual MRI and endoscopy for 3 years. A complete colonoscopy was performed after 1 and 4 years. CEA blood levels were measured every six months for 5 years. Study outcomes included the 3-year locoregional recurrence rate (LRR), 3-year distant recurrence rate (DRR), 3-year salvageable recurrence rate (SRR) and 3-year rectal preservation rate. The 3-year estimates were calculated using the Kaplan-Meier method. Locoregional recurrence was defined as intramural cancer recurrence and/or mesorectal lymph node metastasis, while distant recurrences referred to other cancer recurrences. Salvageable recurrence was defined as cancer recurrence that could be treated with curative intent. Rectal preservation was defined as the absence of completion total mesorectal excision (TME) following EID or cancer recurrence.

Results

EID was initiated in 188 patients (median age 67 years, 33% female, 85% ASA I-II, median lesion size 25 mm) and successfully completed in 177 (94%). Histology showed non-invasive histology in 20 (11%), S-SMIC in 9 (5%), D-SMIC in 94 (53%) and ≥pT2 in 53 (30%) cases. R0 resection rates within these groups were 100%, 100%, 93% and 58%, respectively. Among the 94 D-SMIC cases, 35 (37%) had no histological risk factors other than deep submucosal invasion. Out of the D-SMIC cases, 72/94 (77%) followed a rectal preserving strategy (64/72 close surveillance and 8/72 adjuvant chemoradiotherapy), while 22/94 (23%) underwent completion TME. The median follow-up period within the D-SMIC group was 30 months (IQR 18-48). At three years, the LRR was 5.9% (95%CI 0.0-11.5%) and the DRR was 1.1% (95%CI 0.0-3.4%). The 3-year SRR was 100% (95%CI 100-100%). One patient (1.1%) died of a non-CRC-related cause. Among the subgroup of 35 D-SMIC cases without additional histological risk factors, all of whom underwent close surveillance following EID, no recurrences occurred within the first three years of follow-up. Beyond this period, one locoregional recurrence (2.9%) occurred at 37 months and one distant recurrence (2.9%) at 51 months, both salvageable. Overall, the 3-year rectal preservation rate among all 188 patients who underwent EID for suspected rectal D-SMIC, was 64.6% (95%CI 58.0-71.9%).

Conclusion

EID for suspected rectal D-SMIC resulted in favorable 3-year rectal preservation rates and demonstrated excellent 3-year oncological outcomes for rectal D-SMIC without additional risk factors.

References

1) Moons LMG, Bastiaansen BAJ, Richir MC, Hazen WL, Tuynman J, Elias SG, Schrauwen RWM, Vleggaar FP, Dekker E, Bos P, Fariña Sarasqueta A, Lacle M, Hompes R, Didden P. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy. 2022 Oct;54(10):993-998.