Introduction

Patients with malignant distal biliary obstruction who are eligible for curative resection face the risk of complications from preoperative biliary drainage, especially pancreatitis. Endoscopic ultrasound guided choledochoduodenostomy (EUS-CDS) using a lumen apposing metal stent (LAMS) is a promising alternative for endoscopic retrograde cholangiopancreatography (ERCP) but data in patients undergoing pancreatoduodenectomy (PD) are limited. Therefore, in daily clinical practice multidisciplinary teams are reluctant to opt for EUS-CDS in patients with potentially resectable tumors.

Aims & Methods

Patients who underwent a PD between January 2020 and December 2022 after preoperative biliary drainage by EUS-CDS were included. Prospectively collected data from patients in the Dutch Pancreatic Cancer Audit were retrospectively analyzed. Primary endpoint was major postoperative complications, defined as Clavien-Dindo score ≥3. Secondary endpoints included overall complications, pancreatic surgery specific complications (i.e. postoperative pancreatic fistula, delayed gastric emptying, hemorrhage, and chyle leakage), in-hospital mortality and hospital stay. A propensity score matching (1:3) analysis was performed using patient and tumor characteristics, neoadjuvant therapy, type of stent, and hospital volume. Surgeons who performed a PD in a patient who underwent pre-operative EUS-CDS were requested to fill-out a 5-questions survey directly after the surgical procedure.

Results

Overall, 937 patients after PD were included of which 42 patients underwent EUS-CDS pre-operatively and 895 patients ERCP. Major postoperative complications occurred in 8 patients (19%) in the EUS-CDS group and 292 patients (33%) in the ERCP group (RR 0.50; 95% CI, 0.23-1.07). No significant differences were observed in the secondary endpoints. Time between biliary drainage and surgery in patients without neoadjuvant therapy differed significantly between the EUS-CDS group (median 32 days [IQR 22-39.25]) and the ERCP group (median 41 days [IQR, 28-57]; p=0.005). Operative time was shorter in the EUS-CDS group (median 309 min [IQR 245.75-353] vs 349 min [IQR 281-425]; p=0.002). Results were similar after propensity-score matching.
The survey was completed on 29 resections after EUS-CDS. In the majority (n=22, 76%) there was no direct visualization of the stent during the PD. In most patients, the resection was not (n=13, 45%) or slightly (n=8, 28%) influenced by the EUS-CDS according to the surgeon. The stent did not hamper the creation of the hepaticojejunostomy.

Conclusion

This nationwide retrospective study found EUS-CDS to be safe without increase in (major) postoperative complications after PD as compared to ERCP. Moreover, surgeons did not encounter evident difficulties during most of the resections.

Disclosure

Freek Daams reports research grants from Medtronic, and received speaker ‘s fees from Medtronic, and proctoring fees from Intuitive. Paul Fockens performed as a consultant for Olympus and Cook Endoscopy. Erwin M. van Geenen reports research grants from Olympus, Boston Scientific, and MTW Endoskopie. Peter D. Siersema reports research grants from Pentax and Fujifilm. Roy L.J. van Wanrooij performed as a consultant for Boston Scientific. Rogier P. Voermans reports research grants from Boston Scientific and Prion Medical, performed as a consultant for Boston Scientific, and received speaker’s fees from Mylan and Zambon. All outside the submitted work. The remaining authors have no conflicts of interest or financial ties to disclose.

Introduction

Cholecystectomy is recommended for patients with acute biliary pancreatitis to prevent recurrence and other biliary complications. However, some patients, due to advanced age and comorbidities, are unfit for surgery. The role of endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) in these cases is not well established^1,2.

Aims & Methods

We aimed to evaluate whether ES reduces the risk of recurrent biliary pancreatitis (RBP) in patients unfit for cholecystectomy.
A unicentric retrospective review was conducted including all patients admitted for a first episode of acute biliary pancreatitis between January 2016 and November 2023 at a non-tertiary hospital, who were deemed unfit for cholecystectomy by either surgical or anesthetic teams. Patients with concurrent acute cholangitis at admission or during hospitalization, as well as those with prior cholecystectomy or ES, were excluded. Time-to-event analysis was performed using Kaplan-Meier survival curves.

Results

A total of 169 patients were included, with a mean age of 79.07 ± 8.25 years, and 65% were female. The mean Charlson Comorbidity Index was 5.11 ± 2.09. Most cases (94%) presented as mild or moderately severe pancreatitis. The mean follow-up period was 3.80 ± 1.95 years.
During the index admission, 37% (n=62) underwent ERCP with ES.
Recurrent biliary pancreatitis (RBP) occurred in 35 patients (21%), 97% of whom had not undergone ES. Only one patient in the ES group was readmitted for a new episode of pancreatitis (p<0.001, OR 0.035; 95% CI 0.005–0.265). The mean time to recurrence was 2.67 ± 7.78 months. Kaplan-Meier survival analysis demonstrated a significantly lower cumulative incidence of RBP in the ES group (log-rank p<0.001).
Endoscopic sphincterotomy did not significantly reduce other biliary events, including choledocholithiasis, acute cholangitis, and acute cholecystitis (all p>0.05). There was no statistically significant difference in overall mortality between the two groups (p=0.585).

Conclusion

Our findings suggest that ERCP with ES may effectively reduce the recurrence of gallstone pancreatitis in elderly patients with high surgical-anesthetic risk due to comorbidities. Further studies are needed to refine the selection criteria for these patients.

References

1 - Hwang SS, Li BH, Haigh PI. Gallstone pancreatitis without cholecystectomy. JAMA Surg. 2013 Sep;148(9):867-72.
2 - McAlister, V., Davenport, E., & Renouf, E. (2007). Cholecystectomy deferral in patients with endoscopic sphincterotomy. Cochrane Database of Systematic Reviews.

Introduction

The first-line treatment for obstructed biliary or pancreatic ducts is endoscopic retrograde cholangiopancreatography (ERCP), yet access may fail (even in expert hands) in 10-15% of cases due to inability to cannulate the papilla or a challenging narrow anatomy. Endoscopic ultrasound-guided biliary drainage (EUS-BD) or EUS-guided pancreatic duct drainage (EUS-PDD) have emerged as direct duct accesses alternate to the percutaneous or surgical approach, both which carry high morbidity and mortality.

Aims & Methods

We aim to assess the anterograde’s drainage clinical and technical success in non-neoplastic obstructed biliary and pancreatic ducts. Data from patients with a history of obstructed biliary or pancreatic ducts between January 2021 and October 2022 was analyzed retrospectively. Clinical and technical success were the primary endpoints. Adverse events, re-stenosis, and re-intervention were also evaluated.

Results

A total of twenty patients were included (15/20 EUS-BD and 5/20 EUS-PDD), median age of 46 (IQR 24-77), 70% female. A) EUS-BD: inability to cannulate the papilla was due to stenosis secondary to: 6/15 laparoscopic cholecystectomy, 7/15 conventional cholecystectomy, 1/15 gallbladder neoplastic plastron, and 1/15 Y-Roux. In 4/15 a previous attempt was performed (1/4 balloon dilation, 1/4 percutaneous transhepatic biliary drainage, and 2/4 stenting). Anterograde drainage was performed in 7/15 using a single pigtail stent, 5/15 double pigtail stents and 3/15 lumen-apposing metal stent (LAMS). Stomach puncture was the preferred approach site in 13/15. A 15/15 (100%) technical success was achieved, but a 9/15 (60%) clinical success based on bilirubin decrease. During follow-up, adverse events were documented in 3/15 cases: upper bleeding, cholangitis, and subhepatic fluid collection. Stent migrated in 3/15 cases. There was no restenosis, but reintervention was necessary on 8/15. One patient died. B) EUS-PDD: anterograde drainage was decided due to acute or chronic pancreatitis and choledocholithiasis in 2/5, 1/5, and 2/5 cases, respectively; 2/5 patients were under non-opioids therapy before the procedure for pain management, and 4/5 were prescribed pancreatic enzyme supplementation. In 3/5 cautery-assisted dilation was required. In 1/5, balloon dilation was also necessary. Used stents included: single and double pigtail stents, LAMS, and self-expandable metal stents (SEMS). Technical and clinical success was achieved in 5/5 (100%), with no adverse events.

Conclusion

Anterograde EUS-BD and EUS-PDD for the management of non-neoplastic biliary and pancreatic duct drainage are valuable alternatives in patients where ERCP is not feasible. Further prospective studies are necessary to confirm the observed results.

Disclosure

Carlos Robles-Medranda is a key opinion leader and consultant for Pentax Medical, Boston Scientific, Steris, Medtronic, Motus, Micro-tech, G-Tech Medical Supply, CREO Medical, EndoSound, and mdconsgroup. The other authors declare no conflicts of interest.

Introduction

Peri-pancreatic fluid collections (PFCs) are frequent complications of acute pancreatitis and their management, especially in the presence of necrosis, is often challenging. Invasive interventions are indicated in case of PFC infection or symptoms related to organ compression. Endoscopic ultrasound (EUS)-guided transluminal drainage rapidly developed over time and the introduction of new dedicated stents represented a game changer of PFC treatment. In particular Bi-Flanged Metal Stent (BFMS) and Lumen Apposing Metal Stent (LAMS), with their technical characteristics, facilitate to create a stable connection between the gastrointestinal wall and the target cavity, allowing the introduction of the endoscope through the stent for direct therapeutic intervention, reporting high rates of technical and clinical success. To date, only one retrospective study have compared Nagi and Hot-Axios for EUS-guided drainage of PFCs.

Aims & Methods

The present study aimed to retrospectively evaluate the safety, technical and clinical success of the two different dedicated metal stents for EUS-guided drainage of PFC. Data from a large multicenter series of patients with PFCs treated with Hot-Axios and Nagi stents were retrieved among 30 italian centers during a 5-year period (January 2016–July 2020). Technical and clinical success, rate of adverse events were taken into account as outcome measures. To overcome biases owing to the different distribution of covariates among patients who were treated with the two kinds of stent, a 1-to-1 match was created using propensity score analysis.

Results

Out of 476 patients underwent EUS-guided drainage of PFC, 386 were treated with Hot-Axios and 90 with Nagi stent, with a median follow-up of 290 days (95% CI 244 to 361). After 1:1 propensity score matching two groups were compared, 84 subjects who experienced Hot-Axios and 84 Nagi stent, resulting well comparable in terms of several variables. Median age was 62 (49.5-73) years in the Hot-Axios group and 63 (50-74) years in the Nagi group (p=0.40), male patients were 70% and 61% in the two groups, respectively (p=0.59). WON represented 39% of cases in the Hot-Axios and 32% in the Nagi group (p=0.70); 52% and 61% of PFCs were located in the body of pancreas in the two groups respectively (p=0.62) with a median width of 92 mm (61-120) in the Hot-Axios and 88 mm (56-110) in the Nagi group (p=0.25).
The two stents did not differ in terms of adverse events (AE) rate (13% versus 15%, p=0.29).
Overall, 11 AEs were observed in the Hot-Axios group, of which 3 (3.5%) mild, 4 (4.7%) moderate, 3 (3.5%) severe and 1 (1.1%) fatal, whereas 13 AEs were registered in the Nagi group, of which 3 (3.5%), 5 (5.9%), 3 (3.5%), and 2 (2.3%) mild, moderate, severe and fatal, respectively (p=0.63). Most common AE was bleeding (5.9% in both groups). Collection recurrence was observed in 4 cases after Hot-Axios (4.7%) and 3 cases (3.5%) after Nagi stent (p=1.0).
Technical and clinical success in the two groups were respectively 92% versus 95% (p=0.36) and 91% versus 94% (p=0.64).

Conclusion

Although literature is not univocal on which type of stent offers the best outcome for EUS-guided PFC drainage, our study demonstrates that, among dedicated metal stents, Hot-Axios and Nagi stent have similar technical and clinical success rate with comparable safety profile, suggesting that the choice of one stent over another should be multifactorial, based on clinical and technical aspects and/or personal expertise, rather than just efficacy rate.

Disclosure

Chiara Coluccio is lecturer for Steris.
Andrea Anderloni is consultant for Boston Scientific, Olympus and Medtronic.
Carlo Fabbri is consultant for Boston Scientific and lecturer for Steris and Q3 Medical.
All the other authors have no conflict of interest to declare

Introduction

There has been a shift from percutaneous drainage towards endoscopic ultrasound (EUS)-guided drainage for management of post-operative pancreatic fluid collections (POPFC). However, available series have been limited by sample size and little is known about the factors that may influence clinical success.

Aims & Methods

Our aim was to evaluate the outcomes of EUS-guided drainage of POPFC following pancreatic surgery and identify predictors of clinical success.
We performed a retrospective review of patients who underwent EUS-guided drainage of POPFC between 2014 and August 2024 at three academic centers. Primary outcome was clinical success, defined as the complete radiological regression of the collection and resolution of symptoms without the need for additional drainage procedures.

Results

In total, 265 cases were included (mean age 64 [SD±13.9] years, 37% pylorus-resecting pancreatoduodenectomy). Early drainage (≤14 days) was performed in 52% of cases (n=138) and DPPS were used in 209 cases (79%).
Clinical success with a single EUS drainage procedure was achieved in 160 cases (60.4%). Step-up interventions were required in 67 patients (25.3%), 37 of which required endoscopic revision only. Technical success was achieved in 90% (n=238) and adverse events occurred in 43 cases (16%).
Stent type, drainage timing, splenectomy and drainage route did not seem to significantly influence clinical success. Multivariate analysis including stent type and surgical history, showed that distal pancreatectomy was an independent risk factor for clinical failure.

Conclusion

EUS-guided drainage of POPFC was effective in the majority of cases with a single procedure, although distal pancreatectomy was suggested as an independent risk factor for clinical failure. These results further support the use of EUS-guided drainage for the management of postoperative collections.

Disclosure

HH declares no competing interests. MB received trial support from Boston Scientific and holds consultancy agreements with Dekra, Ovesco and Prion Medical. GV received lecture fees from Boston Scientific and travel grants from Pentax Medical and Euromedical. RVW holds a consultancy agreement with Boston Scientific. Schalk van der Merwe holds the Cook chair in Interventional endoscopy, has consultancy agreements with Cook, Pentax and Olympus and co-chairs the Boston-Scientific Chair in Therapeutic Biliopancreatic Endoscopy.

Introduction

Malignant Gastric Outlet Obstruction (mGOO) has been standardly treated by surgical GastroEnterostomy (S-GE) or Endoscopic Stenting (ES). More recently, EUS GastroEnterostomy (EUS-GE) has emerged as a low-invasive alternative with surgical-range efficacy, supported by guidelines. Nevertheless, its worldwide diffusion is heterogeneous and advantages/disadvantages debated. The aim of this survey is to assess clinical decision-making of international specialists regarding mGOO and to explore current opinion regarding EUS-GE use.

Aims & Methods

An online survey was created exploring centers’ experiences and physicians’ opinions regarding indications, contraindications, benefits and risks of available treatments; 2 case vignettes explored clinical decision-making in different scenarios. The survey was spread through social networks and the EPC newsletter.

Results

Overall, 290 pancreatologists from 44 countries (5 continents) responded, of whom 35% surgeons and 65% gastroenterologists, 44% from centers managing > 20 mGOO/year. The most frequently available treatment for mGOO was ES (91%), followed by S-GE, while EUS-GE was only available to 59% of responders, and only 10% declared proficiency in this technique.
68% referred an established gold-standard in their centers, but this differed by specialty, with ES, EUS-GE and S-GE being advised by 45%, 20% and 10% of gastroenterologists and 24%, 8% and 25% of surgeons.
For 51% of responders, EUS-GE will become the primary treatment for mGOO. This percentage increases among gastroenterologists and high-volume centers. For 14%, EUS-GE spread will be limited in the future, or used only when ES fails (19%), with higher rates among surgeons.
When choosing between alternatives, the main decision driver is life expectancy, followed by disease stage and patient’s frailty, whereas potential future surgical resectability does not contraindicate any treatment for 3/4 of responders. The main perceived advantages of EUS-GE were minimally invasiveness and high clinical efficacy, while the learning curve remains its main disadvantage.

Conclusion

This survey revealed significant differences in the management of mGOO, depending on specialties, local expertise and treatment volume, suggesting the lack of standardized algorithms.
Despite great enthusiasm around EUS-GE, its availability remains suboptimal, with learning curve as the main barrier. Life expectancy and patients’ frailty are likely to remain the main decision factors.