Introduction

EUS-guided choledochoduodenostomy (EUS-CDS) is a minimally invasive procedure used to treat malignant biliary obstruction (MBO) by the transduodenal placement of a lumen-apposing metal stent (LAMS) into the extrahepatic bile duct. In order to identify the factors that contribute to safe and effective EUS-CDS procedures using LAMS we performed a systematic review of the literature with meta-analysis.

Aims & Methods

The methodology of our analysis was based on PRISMA recommendations. Electronic databases (Medline, Scopus, EMBASE) were searched up to November 2022. Full articles including patients with distal malignant biliary obstruction who underwent EUS-CDS using LAMS after failed ERCP were eligible. Technical success, clinical success, and adverse events were pooled by means of a random model. Multivariate meta-regression and subgroup analysis were performed to assess the correlation between outcomes and different variables.

Results

Twelve studies with 845 patients were included in the meta-analysis. Pooled technical and clinical success rates were 96% (95%CI: 94%-98%; I2=52.29%) and 96% (95%CI: 95%-98%), respectively, with no significant association with baseline characteristics, such are sex, age, common bile duct (CBD) diameter and stent size. The pooled AE rate was 12% (95%CI: 8%-16%; I2=71.62%). The AE rate was significantly lower when using an 8x8mm stent as compared to a 6x8 mm LAMS (OR 0.59, 0.35-0.99; p=0.04), with no evidence of heterogeneity (I2=0%).

Conclusion

EUS-CDS with LAMS is confirmed to be a safe and effective option for relief of MBO. The selection of appropriate stent size is crucial for achieving optimal outcomes.

Introduction

EUS-guided choledochoduodenostomy using a lumen-apposing metal stent (EUS-CDSL) has been shown in randomized controlled trials (RCT) to be effective compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with advanced malignant distal biliary obstruction (MDBO). We aimed to further ascertain the safety of EUS-CDSL, which has been limited by inadequate trial sample sizes.

Aims & Methods

We undertook aggregate and individual patient data (IPD) meta-analyses following the PRISMA-IPD statement. A literature search was performed from January 2013 to November 2024 using OVID MEDLINE, EMBASE, Cochrane Library, and ISI Web of Science. Additional searches were performed for abstracts and the grey literature. RCTs comparing EUS-CDSL to ERCP were included. The primary outcome was the rate of procedure-related 14-day severe or fatal adverse events (AE). Secondary outcomes included technical success, 30-day AE, clinical success, stent dysfunction, and procedure time.

Results

A total of 2679 citations were screened with three RCTs included (519 patients). There was no difference in severe or fatal AEs between EUS-CDSL and ERCP (OR 0.64, 95% CI 0.22- 1.83 for IPD data and RR 0.76, 95% CI 0.22, 1.77 for aggregate data). Technical success was greater for EUS-CDSL (OR 4.22, 95% CI 2.35,7.61 and RR 1.14, 95% CI 1.04, 1.25) with shorter procedural time (mean difference -10.50 minutes (95% CI -15.28, -5.73). No significant differences were noted in 30-day AEs, clinical success, and stent dysfunction.

Conclusion

Our aggregate and IPD meta-analyses demonstrate the safety of EUS-CDSL as a first-line alternative to ERCP in advanced MDBO. In addition, EUS-CDSL is technically superior in terms of success rate and procedure time.

Introduction

Endoscopic papillectomy(EP)is a viable treatment option for ampullary lesions(AL).While many studies have reported low morbidity and acceptable outcomes, early attempts to pool data from these initial experiences have produced conflicting conclusions regarding key technical aspects. To address these uncertainties, we conducted a systematic review and pooled analysis to evaluate the safety and efficacy of EP for AL,identifying factors that may influence outcomes.

Aims & Methods

Electronic databases(Medline, Scopus and EMBASE)were searched up to September 2024. Studies that included patients with endoscopically resected AL were eligible. Efficacy and safety outcomes were pooled by means of a random-effects model to obtain a proportion with a 95% confidence interval(CI). Univariable meta-regression analyses were conducted to explore potential factors affecting outcomes.

Results

A total of 60 studies(4,859 lesions)published between 2002 and 2024 were analyzed. Complete resection was achieved in 86.2%of cases, though intraductal involvement limited success. The recurrence rate was 18.6%, however, the majority(89.3%)of patients were managed endoscopically without surgery. The pooled adverse event(AE)rate was 30.0%, with bleeding(12.2%)and post-procedural pancreatitis(11.1%)being the most common complications. Prophylactic stenting reduced pancreatitis risk, while intraductal involvement increased perforation risk.Adjunctive treatments for intraductal involvement were associated with an increased risk of papillary stricture.

Conclusion

Endoscopic papillectomy is a safe and effective treatment for ampullary lesions. However, lesions with intraductal extension pose a higher risk of incomplete resection and perforation, warranting careful evaluation of the benefit-risk balance in these cases. While prophylactic pancreatic stenting may reduce the incidence of post-procedural pancreatitis, optimizing strategies to minimize overall adverse events remains a key focus for future research.

Introduction

Lumen-apposing metal stents (LAMS) provide a conduit to access lumens close to the gastrointestinal tract to perform various interventions. While outcomes of LAMS placement in native anatomy have been reported, data on LAMS placement in surgically altered anatomy (SAA) is sparse.

Aims & Methods

We aim to assess technical, clinical, and safety outcomes of LAMS placement in patients with SAA for different indications. This was an international multicenter retrospective observational study at 25 tertiary-care centers through November 2023. Consecutive patients with SAA who underwent LAMS placement under endoscopic ultrasound guidance were included. Primary outcome was technical success defined as correct placement of LAMS. Secondary outcomes were clinical success and safety.

Results

255 patients with SAA (118 males; average age 61 ± 15 years) underwent LAMS placement. Surgical anatomy included total gastrectomy (n=3; 1.2%) subtotal gastrectomy (n=8; 3.1%), billroth I (n=19; 7.5%) billroth II (n=23; 9.0%), sleeve gastrectomy (n=16; 6.3%), pancreaticoduodenectomy (n=72; 28.2%), total pancreatectomy (n=3; 1.2%), roux-en-y gastric bypass (n=106; 41.6%), partial gastrectomy with roux-en-y (n=3; 1.2%); esophagectomy with partial gastrectomy (n=2; 0.8%). Indications were malignant biliary obstruction (n=32; 12.5%), cholecystitis (n=12; 4.7%), drainage of peri-pancreatic fluid collections (n=46; 18.0%); EUS- guided creation of enteric anastomoses (n=74; 29.0%); endoscopic ultrasound-directed transgastric ERCP (EDGE) (n=82; 32.2%); others (n=9; 3.5%). Both technical and clinical success ranged between 50% to 100%. Overall adverse event rate was 10.6% (n=27/255).

Conclusion

This study shows that placement of LAMS is associated with varying technical and clinical success rates in patients with SAA. The rate of adverse events is noteworthy, and thus, these procedures should be performed by expert endoscopists at tertiary centers.

Introduction

Biliary and gastric outlet obstruction (GOO) are common complications in patients with pancreatic cancer, often delaying essential cancer treatments. While endoscopic ultrasound-guided
gastroenterostomy (EUS-GE) has been shown to be superior to duodenal self-expandable metal stents (dSEMS) for managing GOO, the optimal strategy for biliary drainage (BD) in this setting remains unclear. Specifically, there is no consensus on whether to prefer EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided hepaticogastrostomy (EUS-HGS).

Aims & Methods

We conducted a systematic review and meta-analysis to identify the optimal biliary drainage approach in patients undergoing EUS-GE for concomitant GOO and biliary obstruction. We searched Medline, Scopus, and EMBASE up to February 2025. Studies were included if they reported outcomes of EUS-CDS or EUS-HGS in patients with biliary obstruction and concomitant GOO
treated by EUS-GE. Pooled outcomes included technical and clinical success, stent dysfunction, and adverse events, analyzed using a random-effects model. Results were reported as relative risks (RRs) with 95% confidence intervals (CIs).

Results

Five studies met inclusion criteria, comprising 128 patients (female = 45.5%; mean age range 63.0–73.0 years), with 61 undergoing EUS-CDS and 67 undergoing EUS-HGS. Four studies were conducted in Europe and one in the United States; one study was prospective. Technical success rates were similar between groups (RR 0.96, 95% CI 0.83–1.11; I² = 0%; EUS-CDS 94.5% vs EUS-HGS 96.4%), as were clinical success rates (RR 1.04, 95% CI 0.92–1.19; I² = 0%; EUS-CDS 96.5% vs EUS-HGS 89.1%). However, the risk of stent dysfunction was significantly higher in the EUS-CDS group compared to EUS-HGS (RR 4.42, 95% CI 1.71–11.43; I² = 0%; EUS-CDS 45.1% vs EUS-HGS 10.9%). The incidence of procedure-related adverse events was comparable between the two approaches (RR 1.14, 95% CI 0.24–5.50; I² = 40.8%; EUS-CDS 10.7% vs EUS-HGS 16.0%).

Conclusion

This meta-analysis suggests that both EUS-CDS and EUS-HGS are similarly safe and effective for managing malignant biliary obstruction in the setting of concomitant GOO. However, EUS-CDS is associated with a more than four-fold increase in the risk of stent dysfunction, which may result in delays to critical cancer treatments.

Disclosure

None

Introduction

Despite the increasing diffusion of non-invasive tests for the diagnosis of liver diseases, histological assessment through liver biopsy (LB) is still often mandatory especially in unclear cases. Actually, percutaneous approach (PC-LB) is the gold standard. Nowadays, endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as an established method to achieve liver tissue sampling. EUS-LB has several advantages such as: sampling of both liver lobes, it allows to obtain liver tissue sampling in case of ascites and toavoid damage to nearby organs and vessels.

Aims & Methods

e performed a systematic review with meta-analysis (MA) to evaluate the diagnostic outcomes and safety for liver tissue acquisition of PC-LB and EUS-LB in patients with liver diseases and focal liver lesions. Studies that compare diagnostic outcomes of PC-LB and EUS-LB were identified through literature search usign MEDLINE, Embase and Scopus until January 2024. MA was performed according to a frequentist approach.

Results

Overall, diagnostic adequacy was 94 % (CI 95%, 0.91-0.98, I² = 83.92 %, P < 0.001) for EUS-LB, while 96 % (CI 95%, 0.93-0.99, I² = 91.58 %, P < 0.001) for PC-LB. Moreover, based on eight studies comparison between the two procedures showed an OR 1.89 (95% CI, 0.44 – 8.12, I² = 62.33 %, P=0.003) when comparing PC-LB to EUS-LB. Based on four studies, pooled accuracy was OR 2.45 (95% CI, 0.38 – 15.97, I² = 49.74 %, P=0.0114) when comparing PC-LB to EUS-LB. Regarding safety, based on nine studies, pooled rate of overall adverse events was slightly higher in PC-LB compared to EUS-LB, OR: 1.25 (CI 95%, 0.51 – 3.09 I² = 26.13 %, P=0.212). Technical success for EUS-LB was 99 % (CI 95%, 0.99 - 1.00, I² = 0 %, P = 0.973) while 100 % (CI 95%, 0.99-1.00, I² = 0 %, P =0.973) for PC-LB, with an OR 1.11 (95% CI, 0.26-4.70, I² = 0 %, P=0.988) when comparing PC-LB to EUS-LB. Overall no differences between the two procedures were observed I term of total length specimen with a standardized mean difference of 0.89 (95% CI, -0.87 – 2.64, I² = 98.95 %, P < 0.001) and in term of complete portal tract with a standardized mean difference of 0.50 (95% CI, -0.55 – 1.55, I² = 97.42 %, P < 0.001).

Conclusion

In conclusion, our meta-analysis does not show significant differences between PC-LB and EUS-LB in terms of diagnostic outcomes, albeit EUS-LB is slightly safer than PC-LB.