Introduction

Pancreatic cancers are dramatically increasing. At an advanced stage, pancreatic cancers can cause biliary obstruction (BO) and gastric outlet obstruction (GOO). The coexistence of BO and GOO is not uncommon and can lead to the inability to access the papilla resulting in ERCP failure or impossibility. The development of therapeutic endoscopic ultrasonography (EUS) has created new treatment options for double stenosis management. Optimising nutritional status by appropriate GOO management and an efficient biliary drainage are an important part of the oncological treatment of these patients.
This study aimed to compare the EUS-biliary drainage efficiencies in case of GOO in order to find the best therapeutic strategy.

Aims & Methods

We conducted an international multicenter retrospective study in 10 centers. All patients who underwent EUS-guided choledochoduodenostomy (EUS-CDS) or hepaticogastrostomy (EUS-HGS) between 2017 and 2023 for biliary obstruction that occurred simultaneously or after the management of duodenal obstruction were eligible for inclusion. Patients with previous biliary drainage or a post-procedural follow-up shorter than 30 days (unless death occurs before) were excluded. Patients were followed until death or if they underwent pancreaticoduodenectomy.
Primary outcome was the rate of biliary stent obstruction requiring a new intervention. Secondary outcomes included technical and clinical success (defined as a reduction of bilirubin levels by at least 50 % at day 15 or normalization at day 30) and procedure-related adverse events.

Results

204 patients from 10 centers have been included. The mean age was 70 years [62-78]. The mean bilirubinemia was 162.8 µmol/L (+/- 124.61). 65 % suffered from pancreatic cancer and more than half had a metastatic disease. 12.3 % had ascite. 79.9 % of patients underwent management for simultaneous biliary and gastric outlet obstruction.
The biliary drainage technical success was 96 % and the clinical success was 88 %. 33.3 % were treated by EUS-CDS + enteral stenting (ES) combination (A), 4.4 % by EUS-CDS + EUS-guided gastroenterostomy (EUS-GE) (B), 42.6 % by EUS-HGS + ES (C) and 19.6 % by EUS-HGS + EUS-GE (D).
The median follow-up was 95 days but 84.8 % of the patients died at the end of the follow-up. No difference was observed between the groups in term of technical success and clinical success (respectively p=0.359 and p=0.899).
The post procedural severe adverse events (AGREE ≥ 3) rate was 9.3 % with a significative difference between combinations (A = 4.3 % ; B = 0 % ; C = 15.1 % ; D = 7.5 % ; p = 0.022), occurring more frequently in patients treated with EUS-HGS.
The biliary stent obstruction rate during follow-up was 16.2% with a significative difference between groups (A = 16.4 % ; B = 44.4 % ; C = 21.5 % ; D = 5.1 % ; p = 0.023 %), in favour of EUS-HGS + EUS-GE combination.

Conclusion

Patients suffering from combined BO and GOO have a poor prognostic. The combination of EUS-HGS + EUS-GE appears to be the most effective in reducing the rate of biliary stent dysfunction. However, this efficacy comes at the cost of severe adverse events, suggesting that these fragile patients should be managed in a centre of adequate expertise.

Introduction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a minimally invasive and promising alternative to percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in managing malignant biliary obstruction. Different techniques are available such as choledocoduodenostomy (CDS), gallbladder drainage (GBD) and hepaticogastrostomy HGS). All have been shown to be safe and effective techniques, but which is the most suitable and effective approach is still unknown.

Aims & Methods

We aim to compare the three techniques available in terms of technical success and clinical success, and to assess the adverse events related to the different procedures. Single center retrospective analysis of all consecutive cases of CDS, GBD and HGS acceding to the Therapeutic Endoscopy Unit of Fondazione Policlinico Universitario Campus Bio-Medico of Rome. Data about patients and procedures were collected. Technical success was defined as successful biliary drainage with stent placement. Clinical success was defined as a decrease in total bilirubin level by ⩾30% within 7 days of EUS-BD.

Results

From April 2016 to December 2024 101 patients were included (47.5% male, mean age 74.6 years old), all with malignant biliary obstruction. 52,5% of the subjects (53/101) underwent EUS-CDS, 22,7 % (23/101) underwent EUS-GBD and 24,75% (25/101) underwent EUS-HGS. In 35/101 (34,65%) duodenal stenosis was observed. A total of 7 patients had altered anatomy. The mean procedure time was 26 ± 15,7 minutes. Overall technical success was 93%, 48/53 (90,5%) in the CDS group, 23/23 (100%) in the GBD group and 23/25 (92%) in the HGS group. Overall clinical success was achieved in 57/79 (72%), 29/38 (76,3%) in the CDS group, 12/20 (60%) in the GBD group and 16/21 (76,1%) in the HGS group. When considering a reduction in bilirubin level ⩾50%, the overall clinical success was lower (55%). Adverse events occurred in 6/101 (5,9%) of the patients, 3/53 (5,6%) in the CDS group, 0/23 in the GBD group and 3/25 (12%) in the HGS group. There was no difference in terms of sex, age, altered anatomy, presence of duodenal stenosis and the EUS technique performed. The mean time of the procedure was higher in the HGS group, with a difference statistically significant (CDS=22,87±14,78 min, GBD=26±15,73 min, HGS=41±16,09 min, p=0,005). No difference was observed in terms of technical and clinical success, and adverse events between the three procedures. However, if the reduction in bilirubin level ⩾50% cut-off was used, the HGS was the procedure with the highest rate of clinical success (CDS 59,5% vs GBD 25% vs HGS 76%, p=0,003).

Conclusion

EUS-BD is a safe procedure with high technical and clinical success rate and it s a valid alternative for managing malignant biliary obstruction in high volumes centers. No differences are described between the three approaches. However HGS seems to reduce bilirubin levels more quickly, with longer procedure time.

Introduction

EUS-guided biliary drainage, including choledoco-duodenostomy (EUS-CD) and transmural gallbladder drainage (EUS-GD), is an emerging alternative to ERCP for the treatment of malignant distal biliary obstruction (MDBO).

Aims & Methods

The aim of our study was to compare the efficacy of EUS-CD and EUS-GD in the treatment of MDBO. METHODS: We identified patients with MDBO who underwent either EUS-CD or EUS-GD using a prospective EUS registry. The procedures were performed using Pentax linear echoendoscopes attached to a HITACHI system. Lumen Apposing Metal Stents (LAMS) of 6x8 mm or 8x8 mm were used for EUS-CD and 10x10 mm for EUS-GD. The primary outcome was clinical success, defined as at least a 50% reduction in serum bilirubin levels at 2 weeks. Secondary outcomes included adverse events (AE) and stent occlusion (SO) rates. Data are presented as median (range), frequencies and percentages. Statistical analysis was performed using chi-squared or Fisher's test and Student t test or U-Mann-Whitney test as appropriate.

Results

A total of 42 patients were included in the study (mean age 73.5 years [range 50-90 years], 24 males). Pancreatic adenocarcinoma was diagnosed in 81% of patients, of which 78.6% were unresectable. The clinical characteristics of the patients were similar between the two groups. The common bile duct (CBD) size was 16.7 mm (11.5-25 mm) in the EUS-CD group and 10.3 mm (6-13 mm) in the EUS-GD group. The clinical success rate was 92.6% for EUS-CD and 86.7% for EUS-GD (p=0.06). In five cases (four EUS-CD and one EUS-GD) a plastic pigtail stent (PPS) was initially placed through the LAMS. There were 6 AEs in the EUS-CD group (21.8%) (2 bleeding, 2 infections) and 5 in the EUS-GD group (33.4%) (1 perforation, 4 infections) (p=0.45). Two of the AEs resulted in death. The percentage of SO was 11.1% vs. 40% for EUS-CD and EUS-GD (p=0.04).

Conclusion

EUS-CD and EUS-GD are effective techniques for the treatment of MDBO. Clinical success and SO rate tend to support EUS-CD over EUS-GC. However, it is important to note that the rate of severe AEs is not negligible. Prospective, comparative, randomised studies comparing these two techniques are needed.

Disclosure

Julio Iglesias-García: Advisor Fujifilm

Introduction

Biliary drainage (BD) in patients with distal malignant biliary obstruction (DMBO) implies a higher risk of difficult biliary cannulation (DBC) during endoscopic retrograde cholangiopancreatography (ERCP). When standard techniques, (sphincterotome, and guidewire) fail, the endoscopist may proceed with advanced cannulation techniques, such as the double
guidewire technique, needle-knife precut papillotomy or fistulotomy, and transpancreatic sphincterotomy. Despite the higher risk of adverse events, these advanced strategies can still fail in
up to 15% of cases. In recent times, endoscopic ultrasound-guided biliary drainage (EUS-BD) emerged as a viable alternative in case of DBC due to its favorable profile in terms of both technical success, and safety.

Aims & Methods

Multi-center (4 centers), international (Italy, France), retrospective, propensity score-matched study including patients with DMBO, and common bile duct (CBD) diameter >12mm. DBC cases managed with either advanced cannulation techniques (aERCP group), or direct EUS- guided approach (performed straight away after failure of standard cannulation; EUS-BD group) were considered for the analysis. A 2:1 propensity score-matched analysis was performed balancing age, sex, and CBD diameter to reduce confounding, and ensure comparability between groups. The outcomes of interest were the rates BD failure, clinical success, and adverse events (AEs).

Results

Standard cannulation techniques failed in 524 cases during the study period. Advanced cannulation techniques, and EUS-guided approach were attempted in 472, and 52 cases, respectively. After matching, 76 (aERCP group), and 38 patients (EUS-BD group) were included in the analysis (age: 77.4+10.5 and 76.7+12.6, male: 70.6% vs 71.1%, CBD diameter: 16.5+2.9 and 17.2+3.3, respectively). In aERCP group, also advanced cannulation techniques failed in 17 22.4%) cases, however all these patients were successfully treated by EUS-guided approach as a rescue strategy. No cases of BD failure were reported in EUS-BD group (p<0.05). Clinical success was comparable between the two groups (aERCP:91.2%, vs EUS-BD:94.7%, p=0.46). The 20.6% of patients experienced AEs in the aERCP group (7 cholangitis, 6 pancreatitis, 2 bleeding, 2 other), compared to the 7.9% reported in EUS-BD group (2 cholangitis, 1 pancreatitis, 1 bleeding; p=0.14).

Conclusion

EUS-guided biliary drainage shows higher technical success rate compared to advanced cannulation techniques, with comparable clinical success. Regarding safety, the observed trend of reduced adverse events (AEs) with the EUS-guided approach may require a larger, adequately powered study to confirm statistical significance. In patients with dilated CBD (>12mm).
EUS-BD may be considered an efficient option in case of DBC, possibly minimizing the risk of adverse events.

Introduction

Malignant distal biliary obstruction is a common complication in the progression of pancreatic tumors. Endoscopic ultrasound (EUS) guided drainage can provide effective biliary drainage when not achieved by endoscopic retrograde cholangiopancreatography (ERCP) and can be performed by hepaticogastrostomy or choledocoduodenostomy (CDD). Gallbladder drainage by cholecystogastrostomy (GBD) has been described in small uncontrolled series and could be effective. The objective of this study was to compare the clinical efficacy of CGD vs CDD in distal biliary tract obstruction (DBTO).

Aims & Methods

This was a retrospective, multicenter study (four tertiary centers) including all consecutive patients with DBTO and jaundice who underwent CDD or GBD with a lumen-apposing metal stent (LAMS). The primary outcome was to compare the clinical success rate defined as a decrease of total bilirubin by 50% in 14 days and/or a decrease in total bilirubin below 51 µmol/L after 30 days. Secondary outcomes were technical success, overall survival, survival without biliary reintervention, immediate (within 24 hours) and delayed (>24 hours) morbidity.

Results

78 patients were included between July 2018 and September 2022, 41 GBD and 37 CDD. The mean age was 71 years, and 82% had pancreatic adenocarcinoma, 55% had metastatic disease at diagnosis, and 45% had duodenal stenosis. Most patients (N=59; 76%) had undergone EUS-guided drainage after ERCP failure. The mean diameter of the main bile duct was significantly smaller in the CGD group (13 mm vs. 18 mm; p=0.001). The total bilirubin mean was 196 µmol/L in the GBD group vs. 241 µmol/L in the CDD group; p=0.149. Clinical success was comparable between the two groups: 88% (36/41 - CGD) vs. 89.2% (33/37 - CDD); p=0.848. There was no difference in overall survival (log-rank p=0.727) or survival without biliary obstruction (log-rank p=0.725) between the two groups. Immediate morbidity was comparable: 7% (3/41 - GBD) vs. 13% (5/37 - CDD); p=0.368. The rate of significant immediate complications tended to be lower in the GBD group (5% (2/41 - CGD) vs. 8% (3/37 - CDD); p=0.093). Delayed morbidity (mainly LAMS obstruction) (>24 hours) was lower in the GBD group 7.3% (3/41 - CGD) vs. 27% (10/37 - CDD); p=0.022. There were no biliary complications after the 26th day in the GBD group. The LAMS dimensions did not have an impact on biliary complications in the CGD group (6x8mm vs. 10x10mm vs. 15x10mm).

Conclusion

Biliary drainage of tumoral obstruction of the distal biliary tract by GBD had comparable clinical efficacy and was associated with reduced delayed morbidity compared to CDD. This type of drainage is feasible, especially when the main bile duct is not dilated enough to consider CDD.

References

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