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Spadaccini M, Binda C, Mauro A, Legros R, Colombo M, Giacchetto M, Andreozzi M, Carrara S, Ramai D, Albouys J, Mazza S, Coluccio C, Facciorusso A, Fabbri C, Anderloni A, Hassan C, Jacques J, Repici A, Fugazza A. Impact of endoscopic ultrasound-guided biliary drainage on the management of difficult biliary cannulation in patients with distal malignant biliary obstruction. Endoscopy 2025. [PMID: 39983769 DOI: 10.1055/a-2544-6325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2025]
Abstract
Biliary drainage in patients with distal malignant biliary obstruction (DMBO) carries a higher risk of difficult biliary cannulation (DBC) during endoscopic retrograde cholangiopancreatography (ERCP). After the failure of standard cannulation, endoscopists may proceed with advanced cannulation techniques and/or with endoscopic ultrasound-guided biliary drainage (EUS-BD).This was a retrospective study of consecutive patients with DMBO and a dilated common bile duct (CBD; >12 mm) who underwent ERCP for endoscopic biliary drainage in four European centers. The rates of DBC, technical and clinical success, and procedure-related adverse events (AEs) were assessed. The predictive factors for AEs were also investigated through regression analysis. The EUS-BD approach was considered either as the first option after standard cannulation failure or as the final option after advanced cannulation failure.1016 patients with DMBO were included in the study, with 524 (51.6%) matching the definition of DBC. Clinical success was achieved in 956 patients (94.1%). Procedure-related AEs were experienced by 167 patients (16.4%). Patients with DBC had a higher risk of AEs (P=0.003); however, patients undergoing "early" EUS-BD showed a risk of AEs comparable with those managed with standard cannulation (P=0.38). An attempt at any advanced cannulation technique was independently associated with the occurrence of AEs (P=0.001).The risk of AEs is higher in patients with DMBO and DBC, this appears to be mainly related to the advanced cannulation techniques. In patients with a dilated CBD (>12 mm), "early" EUS-BD may minimize the risk of AEs.
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Affiliation(s)
- Marco Spadaccini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Cecilia Binda
- Digestive Endoscopy and Gastroenterology Unit, Forlì-Cesena Hospitals, Azienda Unita Sanitaria Locale della Romagna, Forlì-Cesena, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Romain Legros
- Hepatogastroenterology Unit, CHU de Limoges, Limoges, France
| | - Matteo Colombo
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marco Giacchetto
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Marta Andreozzi
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, United States
| | - Jérémie Albouys
- Hepatogastroenterology Unit, CHU de Limoges, Limoges, France
| | - Stefano Mazza
- Gastroenterology & Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Coluccio
- Digestive Endoscopy and Gastroenterology Unit, Forlì-Cesena Hospitals, Azienda Unita Sanitaria Locale della Romagna, Forlì-Cesena, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Experimental Medicine, University of Salento, Lecce, Italy
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
| | - Carlo Fabbri
- Digestive Endoscopy and Gastroenterology Unit, Forlì-Cesena Hospitals, Azienda Unita Sanitaria Locale della Romagna, Forlì-Cesena, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Jérémie Jacques
- Hepatogastroenterology Unit, CHU de Limoges, Limoges, France
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
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Fritzsche JA, Fockens P, Besselink MG, Busch OR, Daams F, Wielenga MCB, Wilmink JW, Voermans RP, Van Wanrooij RLJ. Optimizing EUS-guided choledochoduodenostomy with lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-IIp): a prospective pilot study. Gastrointest Endosc 2025; 101:1009-1016. [PMID: 39424003 DOI: 10.1016/j.gie.2024.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/27/2024] [Accepted: 10/10/2024] [Indexed: 10/21/2024]
Abstract
BACKGROUND AND AIMS Biliary drainage by ERCP in patients with malignant distal bile duct obstruction (MBO) is frequently associated with adverse events, such as pancreatitis, hampering patient outcomes. EUS-guided choledochoduodenostomy (EUS-CDS) with a lumen-apposing metal stent (LAMS) is a promising alternative in patients with MBO but is associated with a worrisome risk of stent dysfunction. Placement of a fully covered self-expandable metal stent (FCSEMS) through the LAMS, thereby changing the axis of biliary drainage toward the descending duodenum, may decrease the risk of stent dysfunction while maintaining high technical success and low adverse event rates. METHODS This was a prospective single-center pilot study in patients with pathology-confirmed MBO without gastric outlet obstruction. The primary outcome was stent dysfunction, defined as recurrent jaundice after initial clinical success, ongoing jaundice in combination with persistent bile duct dilatation, or cholangitis. RESULTS Overall, 27 consecutive patients eligible for EUS-CDS were enrolled. The placement of a LAMS was successful in 24 of 27 patients (89%), and placement of a FCSEMS through the LAMS was successful in 20 of 24 (83%); in the remaining 4 patients, a coaxial double-pigtail plastic stent was placed. Two of these 20 patients experienced persistent jaundice requiring stent revision (10%), leading to a clinical success rate of 90%. No patients developed stent dysfunction after initial clinical success. CONCLUSIONS This study showed a stent dysfunction rate of 10% after technically successful EUS-CDS with placement of a FCSEMS through the LAMS. Improving the design of LAMSs may further reduce the rate of stent dysfunction. (Clinical trial registration number: NCT05595122.).
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Affiliation(s)
- Jeska A Fritzsche
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Olivier R Busch
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Freek Daams
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Department of Surgery, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - Mattheus C B Wielenga
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, The Netherlands; Department of Medical Oncology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roy L J Van Wanrooij
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
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Chen YI, Long C, Sahai AV, Napoleon B, Donatelli G, Kunda R, Martel M, Chan SM, Arcidiacono PG, Lam E, Kongkam P, Forbes N, Larghi A, Mosko JD, Van der Merwe S, Gan SI, Jacques J, Kenshil S, Ratanachu-Ek T, Miller C, Saxena P, Desilets E, Sandha G, Alrifae Y, Teoh AYB. Stent misdeployment and factors associated with failure in endoscopic ultrasound-guided choledochoduodenostomy: analysis of the combined datasets from two randomized trials. Endoscopy 2025; 57:330-338. [PMID: 39505002 DOI: 10.1055/a-2463-1601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2024]
Abstract
BACKGROUND Stent misdeployment (SMD) is a feared and poorly characterized technical challenge of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) using lumen-apposing stents. We aimed to ascertain the rate of stent misdeployment in EUS-CDS for malignant distal biliary obstruction (MDBO) and describe its outcomes while identifying variables associated with its occurrence. METHOD This was a post hoc analysis of two randomized controlled trials comparing EUS-CDS vs. endoscopic retrograde cholangiopancreatography in MDBO. The primary end point was rate of SMD, classified as misdeployment of the distal flange (type I), proximal flange (type II), contralateral bile duct wall injury (type III), or double mucosal puncture (type IV). Multivariable analysis was performed to identify variables associated with SMD and/or technical failure, and with clinical failure or stent dysfunction. RESULTS 152 patients were included. Technical success was 93.4 %. SMD occurred in 11 patients (7.2 %; 95 %CI 3.1 %-11.4 %): 8 type I, 1 type II, and 2 type III. Endoscopic salvage of SMD was successful in 81.8 %. Misdeployment led to adverse events in four patients (two mild, two moderate), giving an overall SMD-related adverse event rate of 2.6 % (95 %CI 0.7 %-6.6 %). On multivariable analysis, extrahepatic bile duct diameter of ≤ 15 mm was associated with increased odds of SMD and/or technical failure. CONCLUSION SMD was relatively common in EUS-CDS and was associated with an extrahepatic bile duct diameter of ≤ 15 mm. The majority of misdeployments could be rescued endoscopically with low risk for adverse events.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Clara Long
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Anand V Sahai
- Service de Gastroentérologie, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | | | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Paris, France
| | - Rastislav Kunda
- Department of Surgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Gastroenterology-Hepatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Myriam Martel
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Shannon M Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Paolo G Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, Milan, Italy
| | - Eric Lam
- Division of Gastroenterology and Hepatology, St-Paul Hospital, Vancouver, British Columbia, Canada
| | - Pradermchai Kongkam
- Division of Hospital and Ambulatory Medicine and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Jeffrey D Mosko
- Division of Gastroenterology, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, The University of Leuven, Leuven, Belgium
| | - Seng Ian Gan
- Division of Gastroenterology and Hepatology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jeremie Jacques
- Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | - Sana Kenshil
- Division of Gastroenterology and Hepatology, Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Corey Miller
- Division of Gastroenterology and Hepatology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sidney, Australia
| | - Etienne Desilets
- Division of Gastroenterology, Hôpital Charles-Le Moyne, Longeuil, Quebec, Canada
| | - Gurpal Sandha
- Division of Gastroenterology and Hepatology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Yousef Alrifae
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Anthony Y B Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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Debourdeau A, Daniel J, Caillo L, Assenat E, Bertrand M, Bardol T, Souche F, Pouderoux P, Gerard R, Lorenzo D, Bourgaux J. Effectiveness of endoscopic ultrasound (EUS)-guided choledochoduodenostomy vs. EUS-guided gallbladder drainage for jaundice in patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography: Retrospective, multicenter study (GALLBLADEUS Study). Dig Endosc 2025; 37:103-114. [PMID: 38380564 PMCID: PMC11718144 DOI: 10.1111/den.14750] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/24/2023] [Indexed: 02/22/2024]
Abstract
OBJECTIVES The aim of this study was to compare endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) vs. EUS-gallbladder drainage (EUS-GBD) in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) for jaundice resulting from malignant distal biliary obstruction (MDBO). METHODS This multicenter retrospective study included patients with obstructive jaundice secondary to MDBO who underwent EUS-GBD or EUS-CDS with lumen-apposing metal stents after failed ERCP. The primary end-point was clinical success rate. Secondary end-points were technical success, periprocedural adverse events rate (<24 h), late adverse events rate (>24 h), overall survival, and time to recurrent biliary obstruction. RESULTS A total of 78 patients were included: 41 underwent EUS-GBD and 37 underwent EUS-CDS. MDBO was mainly the result of pancreatic cancer (n = 63/78, 80.7%). Clinical success rate was similar for both procedures: 87.8% for EUS-GBD and 89.2% for EUS-CDS (P = 0.8). Technical success rate was 100% for EUS-GBD and 94.6% for EUS-CDS (P = 0.132). Periprocedural morbidity (<24 h) rates were similar between both groups: 4/41 (9.8%) for EUS-GBD and 5/37 (13.5%) for EUS-CDS (P = 0.368). There was a significantly higher rate of late morbidity (>24 h) among patients in the EUS-CDS group (8/37 [21.6%]) than in the EUS-GBD group (3/41 [7.3%]) (P = 0.042). The median follow-up duration was 4.7 months. Overall survival and time to recurrent biliary obstruction did not significantly differ between the groups. DISCUSSION After failed ERCP for MDBO, EUS-GBD and EUS-CDS show comparable clinical success rates and technical success. EUS-GBD appears to be a promising alternative for MDBO, even as a second-line treatment after failed ERCP. Further studies are needed to validate these findings and compare the long-term outcomes of EUS-GBD and EUS-CDS.
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Affiliation(s)
- Antoine Debourdeau
- Hepatogastroenterology DepartmentNimes University Hospital, University of MontpellierNimesFrance
- Hepatogastroenterology DepartmentMontpellier University Hospital, University of MontpellierMontpellierFrance
| | - Jules Daniel
- Hepatogastroenterology DepartmentNimes University Hospital, University of MontpellierNimesFrance
| | - Ludovic Caillo
- Hepatogastroenterology DepartmentNimes University Hospital, University of MontpellierNimesFrance
| | - Eric Assenat
- Hepatogastroenterology DepartmentMontpellier University Hospital, University of MontpellierMontpellierFrance
| | - Martin Bertrand
- Surgery DepartmentNimes University Hospital, University of MontpellierNimesFrance
| | - Thomas Bardol
- Surgery DepartmentMontpellier University Hospital, University of MontpellierMontpellierFrance
| | - François‐Régis Souche
- Surgery DepartmentMontpellier University Hospital, University of MontpellierMontpellierFrance
| | - Philippe Pouderoux
- Hepatogastroenterology DepartmentNimes University Hospital, University of MontpellierNimesFrance
| | - Romain Gerard
- Hepatogastroenterology DepartmentLille University Hospital, Lille UniversityLilleFrance
| | - Diane Lorenzo
- Hepatogastroenterology DepartmentBeaujon University Hospital, Paris Cité UniversityParisFrance
| | - Jean‐François Bourgaux
- Hepatogastroenterology DepartmentNimes University Hospital, University of MontpellierNimesFrance
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Wahba G, Lee JH. Updates on therapeutic endoscopic ultrasound. Curr Opin Gastroenterol 2025; 41:16-28. [PMID: 39560626 DOI: 10.1097/mog.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2024]
Abstract
PURPOSE OF REVIEW Multiple endoscopic ultrasound (EUS) guided therapeutic interventions have been developed for the management of benign and malignant pancreaticobiliary and gastrointestinal luminal pathology. Recent high-quality evidence is increasingly validating these interventions and positioning them within evidence-based therapeutic algorithms. RECENT FINDINGS Here we review therapeutic EUS-guided interventions including pancreatic fluid collection drainage, gastroenterostomy, biliary drainage, pancreatic duct drainage and gallbladder drainage. The most up-to-date high-quality evidence supporting these interventions is presented including comparative data with other conventional treatment options. Newer emerging interventions such as tumor ablation are also reviewed. Current controversies and future avenues for research are discussed. The key role of EUS-guided interventions in managing pancreaticobiliary pathology in patients with a surgically altered anatomy is highlighted. SUMMARY Multiple EUS therapeutic interventions have evolved from experimental or rescue options to now well established first- and second-line interventions over other endoscopic, percutaneous and surgical alternatives with the support of high-quality data. Further research is needed to better optimize patient selection and guide long term postintervention follow-up.
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Affiliation(s)
- George Wahba
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Dell’Anna G, Nunziata R, Delogu C, Porta P, Grassini MV, Dhar J, Barà R, Bencardino S, Fanizza J, Mandarino FV, Fasulo E, Barchi A, Azzolini F, Albertini Petroni G, Samanta J, Facciorusso A, Dell’Anna A, Fuccio L, Massironi S, Malesci A, Annese V, Pagano N, Donatelli G, Danese S. The Role of Therapeutic Endoscopic Ultrasound in Management of Malignant Double Obstruction (Biliary and Gastric Outlet): A Comprehensive Review with Clinical Scenarios. J Clin Med 2024; 13:7731. [PMID: 39768654 PMCID: PMC11677180 DOI: 10.3390/jcm13247731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Revised: 12/15/2024] [Accepted: 12/16/2024] [Indexed: 01/11/2025] Open
Abstract
Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life.
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Affiliation(s)
- Giuseppe Dell’Anna
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy; (C.D.); (G.A.P.); (V.A.)
| | - Rubino Nunziata
- Department of Gastroenterology, Ospedale del Mare, ASL NA1 Centro, 80147 Naples, Italy;
| | - Claudia Delogu
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy; (C.D.); (G.A.P.); (V.A.)
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, 27100 Pavia, Italy
| | - Petra Porta
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (P.P.); (M.V.G.); (N.P.)
| | - Maria Vittoria Grassini
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (P.P.); (M.V.G.); (N.P.)
| | - Jahnvi Dhar
- Department of Gastroenterology and Hepatology, Punjab Institute of Liver and Biliary Sciences, Mohal 160062, India;
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India;
| | - Rukaia Barà
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Sarah Bencardino
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Jacopo Fanizza
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Francesco Vito Mandarino
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Ernesto Fasulo
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Alberto Barchi
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Francesco Azzolini
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
| | - Guglielmo Albertini Petroni
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy; (C.D.); (G.A.P.); (V.A.)
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India;
| | - Antonio Facciorusso
- Faculty of Medicine and Surgery, University of Salento, Piazza Tancredi 7, 73100 Lecce, Italy;
| | - Armando Dell’Anna
- Digestive Endoscopy Unit, “Vito Fazzi” Hospital, Piazza Filippo Muratore 5, 73100 Lecce, Italy;
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, 40100 Bologna, Italy;
| | - Sara Massironi
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Alberto Malesci
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Vito Annese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy; (C.D.); (G.A.P.); (V.A.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Nico Pagano
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (P.P.); (M.V.G.); (N.P.)
| | - Gianfranco Donatelli
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, 75013 Paris, France;
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80138 Naples, Italy
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; (R.B.); (S.B.); (J.F.); (F.V.M.); (E.F.); (A.B.); (F.A.); (A.M.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
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Sundaram S, Giri S, Binmoeller K. Lumen-apposing metal stents: A primer on indications and technical tips. Indian J Gastroenterol 2024; 43:886-895. [PMID: 38717660 DOI: 10.1007/s12664-024-01562-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/28/2024] [Indexed: 10/07/2024]
Abstract
Lumen-apposing metal stents have ushered a new frontier for interventional endoscopic ultrasound. Initial use for the drainage of pancreatic fluid collections has rapidly expanded to the bile duct, gallbladder and small bowel. Intra-luminal applications for short strictures have also emerged. Electrocautery enhancement has made the stent delivery speedy. While the advent of lumen-apposing metal stents (LAMS) has brought a paradigm shift in the practice of interventional endoscopic ultrasound, their use is associated with certain technicalities that any advanced endosonologist should know. Understanding indications for LAMS is critical and their use in appropriate settings. Troubleshooting in tricky situations is always a challenge and the background considerations for their use include knowing the target organ, cautery and puncture technique, managing partially opened LAMS and also managing maldeployment. In this review, we discuss the intricacies and technical tips for the use of lumen-apposing metal stents.
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Affiliation(s)
- Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Dr. E Borges Road, Parel, Mumbai, 400 012, India.
| | - Suprabhat Giri
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneshwar, 751 024, India
| | - Kenneth Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA, USA
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Troncone E, Amendola R, Moscardelli A, De Cristofaro E, De Vico P, Paoluzi OA, Monteleone G, Perez-Miranda M, Del Vecchio Blanco G. Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:633. [PMID: 38674279 PMCID: PMC11052411 DOI: 10.3390/medicina60040633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
In recent years, therapeutic endoscopy has become a fundamental tool in the management of gallbladder diseases in light of its minimal invasiveness, high clinical efficacy, and good safety profile. Both endoscopic transpapillary gallbladder drainage (TGBD) and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) provide effective internal drainage in patients with acute cholecystitis unfit for cholecystectomy, avoiding the drawbacks of external percutaneous gallbladder drainage (PGBD). The availability of dedicated lumen-apposing metal stents (LAMS) for EUS-guided transluminal interventions contributed to the expansion of endoscopic therapies for acute cholecystitis, making endoscopic gallbladder drainage easier, faster, and hence more widely available. Moreover, EUS-GBD with LAMS opened the possibility of several cholecystoscopy-guided interventions, such as gallstone lithotripsy and clearance. Finally, EUS-GBD has also been proposed as a rescue drainage modality in malignant biliary obstruction after failure of standard techniques, with encouraging results. In this review, we will describe the TBGD and EUS-GBD techniques, and we will discuss the available data on clinical efficacy in different settings in comparison with PGBD. Finally, we will comment on the future perspectives of EUS-GBD, discussing the areas of uncertainty in which new data are more strongly awaited.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Rosa Amendola
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Elena De Cristofaro
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Pasquale De Vico
- Department of Anaesthesia, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Manuel Perez-Miranda
- Department of Gastroenterology and Hepatology, University Hospital Rio Hortega, 47012 Valladolid, Spain
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Fritzsche JA, Van Wanrooij RLJ, Voermans RP. EUS-guided Choledochoduodenostomy: Taking the Shortcut, But Still a Long Way to Go. Gastroenterology 2024; 166:216-217. [PMID: 37290702 DOI: 10.1053/j.gastro.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Jeska A Fritzsche
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, and, Amsterdam Gastroenterology Endocrinology Metabolism and, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roy L J Van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, and, Amsterdam Gastroenterology Endocrinology Metabolism and, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, and, Amsterdam Gastroenterology Endocrinology Metabolism and, Cancer Center Amsterdam, Amsterdam, The Netherlands
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10
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Fritzsche JA, Fockens P, Besselink MG, Busch OR, Daams F, Montazeri NSM, Wilmink JW, Voermans RP, Van Wanrooij RLJ. Endoscopic ultrasound-guided choledochoduodenostomy using single-step lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-p): a prospective pilot study. Endoscopy 2024; 56:47-52. [PMID: 37473780 PMCID: PMC11321721 DOI: 10.1055/a-2134-3537] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/20/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND This study aimed to assess the safety and feasibility of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) using a lumen-apposing metal stent (LAMS) as a primary drainage strategy in patients with distal malignant biliary obstruction (MBO). METHODS A prospective, single-center, pilot study was conducted in patients with pathology-confirmed MBO without gastric outlet obstruction. The primary outcome was technical success. Secondary outcomes included clinical success, adverse events (AEs), and reinterventions. The study was registered in the Netherlands Trial Registry (registry number NL9757). RESULTS 22 patients were enrolled (median age 69.5 years [interquartile range 64-75.3]). Technical success was achieved in 20/22 patients (91 %). AEs occurred in one patient, namely perforation following inadequate stent deployment (5 %), which was treated in the same procedure. Clinical success was achieved in 19/22 patients (86 %). Stent dysfunction was observed in 11/20 patients (55 %) after technically successful EUS-CDS: two patients were treated conservatively and nine patients underwent reintervention(s). One patient died within ≤ 30 days due to fulminant disease progression. CONCLUSIONS The results confirmed the safety and feasibility of EUS-CDS using LAMS as a primary drainage strategy. The high incidence of stent dysfunction should be improved before EUS-CDS with LAMS can be seen as a valid alternative to endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Jeska A. Fritzsche
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location
University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The
Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location
University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The
Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije
Universiteit, Amsterdam, The Netherlands
| | - Marc G. Besselink
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The
Netherlands
- Department of Surgery, Amsterdam UMC, location University of Amsterdam,
Amsterdam, The Netherlands
| | - Olivier R. Busch
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The
Netherlands
- Department of Surgery, Amsterdam UMC, location University of Amsterdam,
Amsterdam, The Netherlands
| | - Freek Daams
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The
Netherlands
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit, Amsterdam,
The Netherlands
| | - Nahid S. M. Montazeri
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Biostatistics Unit, Amsterdam
UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna W. Wilmink
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The
Netherlands
- Department of Medical Oncology, Amsterdam UMC, location University of
Amsterdam, Amsterdam, The Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location
University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The
Netherlands
| | - Roy L. J. Van Wanrooij
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute,
Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The
Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije
Universiteit, Amsterdam, The Netherlands
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Zhou X, Liu Z, Ma W, Sheng S, Sun S, Ge N. Standardized construction of a porcine model for acute obstructive jaundice and training of endoscopic ultrasound-guided choledochoduodenostomy. Front Oncol 2023; 13:1247763. [PMID: 38074676 PMCID: PMC10702982 DOI: 10.3389/fonc.2023.1247763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/02/2023] [Indexed: 02/06/2025] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for patients with obstructive jaundice. However, it is still a challenge for many endoscopists because of its novelty and complexity. This study aimed to establish an ideal bile duct dilatation model for the training and practice of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS). METHODS The 34 healthy Bama miniature pigs were divided into the part of developing the standardized EUS-CDS (n=9) and the part of trainees training (n=25). Part one, two different methods were used to clip Vater's ampulla using metal clips to establish an extrahepatic bile duct dilatation model. Part two, five trainees were trained on EUS-CDS with 25 pigs. Following a 2-week observation period, the feasibility and effectiveness of the technique were evaluated. RESULTS In the group with three metal clips perpendicular to the duodenal wall clipping Vater's ampulla, the success rate of extrahepatic bile duct dilation greater than 1 cm in 24 h was 5/6, whereas the remaining one pig was 48 h. All five trainees can finally complete the EUS-CDS independently. No death occurred during the 2-week observation period. CONCLUSION Clipping Vater's ampulla with three metal clips perpendicular to the duodenal wall is an effective and stable method to create a porcine bile duct dilatation model.
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Affiliation(s)
| | | | | | | | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Nan Ge
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
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12
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Gantschnigg A, Singhartinger F, von Rahden B, Mühlbacher I, Koch OO, Emmanuel K, Holzinger J. Real-life Indications and Outcome of Electrocautery-enhanced Lumen-apposing Metal Stents in a Tertiary Center. Surg Laparosc Endosc Percutan Tech 2023; 33:527-532. [PMID: 37523520 DOI: 10.1097/sle.0000000000001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/19/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE Electrocautery-enhanced lumen-apposing stents (EC-LAMS) were originally designed for the drainage of the gallbladder, bile duct, and pancreas pseudocysts. Throughout the years, several off-label indications were established. This study aims to evaluate the indication, safety, efficacy, and outcome of all LAMS implanted in a single tertiary referral center. METHODS From April 2016 to April 2022, all patients undergoing LAMS placement in a single tertiary center were included. We present a detailed analysis of indications, success rates, and complications based on a retrospective analysis of our prospectively maintained database. RESULTS A total of 86 stents were placed in 77 patients between April 2016 and April 2022. Indications were walled-off pancreatic necrosis (25.6%), bile duct obstructions (16.3%), acute cholecystitis (15.1%), pancreas pseudocysts (15.1%), postoperative collections (10.5%), postoperative pancreatic fistulas (9.3%), and gastro-gastrostomy/jejunostomy (8.1%) to enable to perform an endoscopic retrograde cholangiopancreatography in patients with gastric bypass. Technical success was 97.7% (84 out of 86). A total of 10 (11.7%) adverse events were observed. In 3 patients (3.5%), severe complications occurred, which required acute surgery; one displacement was closed through clips. In 7 patients (8.2%), bleedings occurred during necrosectomy or from mucosal erosions at the stent side, respectively, that were treated with endoclips. CONCLUSIONS EC-LAMS are safe and show a high technical success rate in all indications. In everyday clinical practice, the main indications are hepato-pancreato-biliary, and therefore an hepato-pancreato-biliary-surgical department should have EC-LAMS in their armamentarium.
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Armellini E, Metelli F, Anderloni A, Cominardi A, Aragona G, Marini M, Pace F. Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: A systematic review focusing on issues and rescue management. World J Gastroenterol 2023; 29:3341-3361. [PMID: 37377584 PMCID: PMC10292149 DOI: 10.3748/wjg.v29.i21.3341] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/01/2023] [Accepted: 05/06/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND The introduction of lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings. Nevertheless, the procedure may conceal unexpected pitfalls. LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences. Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. To date, no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.
AIM To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (EUS-PFC) and to describe the endoscopic rescue strategies adopted under the circumstance.
METHODS We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022. The search was carried out using the exploded medical subject heading terms “lumen apposing metal stent”, “LAMS”, “endoscopic ultrasound” and “choledochoduodenostomy” or “gallbladder” or “pancreatic fluid collections”. We included in the review on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. Only those publications reporting EUS-guided LAMS positioning were considered. The studies reporting a technical success rate of 100% and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment, while studies not reporting the causes of technical failure were excluded. Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques. The following data were collected from each study: Author, year of publication, study design, study population, clinical indication, technical success, reported number of misdeployment, stent type and size, flange misdeployed and type of rescue strategy.
RESULTS The overall technical success rate of EUS-CDS, EUS-GBD and EUS-PFC was 93.7%, 96.1%, and 98.1% respectively. Significant rates of LAMS misdeployment have been reported for EUS-CDS, EUS-GBD and EUS-PFC drainage, respectively 5.8%, 3.4%, and 2.0%. Endoscopic rescue treatment was feasible in 86.8%, 80%, and 96.8% of cases. Non endoscopic rescue strategies were required only in 10.3%, 16% and 3.2% for EUS-CDS, EUS-GBD, and EUS-PFC. The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%, 8% and 64.5% and stent-in-stent in 23.5%, 60%, and 12.9%, respectively for EUS-CDS, EUS-GBD, and EUS-PFC. Further therapeutic option were endoscopic rendezvous in 11.8% of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1% of EUS-PFC.
CONCLUSION LAMS misdeployment is a relatively common adverse event in EUS-guided drainages. There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario, anatomical characteristics, and local expertise. In this review, we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used, with the aim of providing useful data for endoscopists and to improve patient outcomes.
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Affiliation(s)
- Elia Armellini
- Department of Gastroenterology, ASST-Bergamoest, Seriate 24068, Bergamo, Italy
| | - Flavio Metelli
- Department of Gastroenterology, ASST-Bergamoest, Seriate 24068, Bergamo, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia 27100, Italy
| | - Anna Cominardi
- Department of Gastroenterology, “Guglielmo da Saliceto” Hospital, Piacenza 29121, Italy
| | - Giovanni Aragona
- Department of Gastroenterology, “Guglielmo da Saliceto” Hospital, Piacenza 29121, Italy
| | - Michele Marini
- Department of General Surgery, ASST-Bergamoest, Seriate 24068, Italy
| | - Fabio Pace
- Department of Gastroenterology, ASST-Bergamoest, Seriate 24068, Bergamo, Italy
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Voiosu TA, Rimbaș M, Larghi A. The Role of Lumen Apposing Metal Stents in the Palliation of Distal Malignant Biliary Distal Obstruction. Cancers (Basel) 2023; 15:2730. [PMID: 37345067 PMCID: PMC10216748 DOI: 10.3390/cancers15102730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023] Open
Abstract
Malignant biliary obstruction (DMBO) has been traditionally managed by endoscopic retrograde cholangiopancreatography (ERCP). In the case of ERC failure, percutaneous transhepatic biliary drainage (PT-BD) has been widely utilized as a salvage procedure. However, over the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has gained increasing popularity, especially after the advent of electrocautery-enhanced lumen apposing metal stent devices (EC-LAMSs) which enable a one-step procedure, granting prevention of biliary leakage and minimizing occurrence of adverse events (AEs). In parallel, increasing evidence suggests a possible role of EUS-BD in the management of DMBO as a primary palliative drainage modality. In the current paper, we aim to review all the available evidence on the role of EUS-BD performed with EC-LAMSs and discuss salient technical aspects of this type of procedure.
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Affiliation(s)
- Theodor Alexandru Voiosu
- Carol Davila Faculty of Medicine, 021155 Bucharest, Romania; (T.A.V.); (M.R.)
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Mihai Rimbaș
- Carol Davila Faculty of Medicine, 021155 Bucharest, Romania; (T.A.V.); (M.R.)
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Alberto Larghi
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, 00168 Rome, Italy
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Dell'Anna G, Ogura T, Vanella G, Nishikawa H, Lakhtakia S, Arcidiacono PG. Endoscopic ultrasound guided biliary interventions. Best Pract Res Clin Gastroenterol 2022; 60-61:101810. [PMID: 36577530 DOI: 10.1016/j.bpg.2022.101810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP), even in expert hands, may fail in 5-10% of cases, especially in cases of papillary infiltration, malignant gastric outlet obstruction, or surgically altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has represented the traditional rescue therapy, despite associated with high rate of adverse events, need for re-interventions and an inferior quality of life. The evolution of Endoscopic Ultrasound (EUS) from a diagnostic to a therapeutic tool offers an effective and safe alternative for internal biliary drainage (BD) into the stomach or the duodenum. EUS-BD is reported to have similar or even improved efficacy and increased safety when compared to PTBD and can be performed in the same session of a failed ERCP. This review summarizes technical aspects of intra-hepatic and extra-hepatic EUS-BD (including hepatico-gastrostomy, choledocho-duodenostomy and rendezvous) together with current evidence and future perspectives that steadily cements EUS-BD's place in multidisciplinary management of bilio-pancreatic diseases.
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Affiliation(s)
- Giuseppe Dell'Anna
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Takeshi Ogura
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Hiroki Nishikawa
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Vanella G, Dell’Anna G, Bronswijk M, van Wanrooij RL, Rizzatti G, Gkolfakis P, Larghi A, van der Merwe S, Arcidiacono PG. Endoscopic ultrasound-guided biliary drainage and gastrointestinal anastomoses: the journey from promising innovations to standard of care. Ann Gastroenterol 2022; 35:441-451. [PMID: 36061163 PMCID: PMC9399569 DOI: 10.20524/aog.2022.0736] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/01/2022] [Indexed: 11/11/2022] Open
Abstract
Biliary obstruction (BO) and gastric outlet obstruction (GOO) are frequent complications of pancreatobiliary and gastroduodenal neoplasia, which can severely impact oncological outcomes, patient survival and quality of life. Although endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for biliary drainage, this may fail or be unfeasible because of duodenal/papillary infiltration or surgically-altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has been the standard rescue therapy in this setting, but is burdened by high morbidity and reduced quality of life. As for GOO, surgical gastroenterostomy and enteral stenting are limited by invasiveness and suboptimal long-term outcomes, respectively. Endoscopic ultrasound (EUS) has evolved from a diagnostic to a therapeutic modality, providing a safe and effective alternative for draining the pancreatobiliary tract into the stomach or duodenum. EUS-guided biliary drainage (EUS-BD) has already demonstrated similar efficacy, greater safety and fewer reinterventions compared to PTBD, and can be performed in the same session after ERCP failure. Further development of lumen apposing metal stents has paved the way towards the creation of EUS-guided anastomoses. EUS-guided gastroenterostomy (EUS-GE) is nowadays increasingly used to treat GOO, combining the minimal invasiveness of endoscopy with surgical-range efficacy. This review summarizes the technical details, current evidence and society recommendations contributing to EUS-BD and EUS-GE gaining ground in everyday practice or tertiary referral centers and becoming crucial in improving the multidisciplinary management of cancer-related symptoms.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute and University, Milan, Italy (Giuseppe Vanella, Giuseppe Dell’Anna, Paolo Giorgio Arcidiacono)
| | - Giuseppe Dell’Anna
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute and University, Milan, Italy (Giuseppe Vanella, Giuseppe Dell’Anna, Paolo Giorgio Arcidiacono)
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium (Michiel Bronswijk, Schalk van der Merwe)
- Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium (Michiel Bronswijk)
| | - Roy L.J. van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit, Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, The Netherlands (Roy L.J. van Wanrooij)
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, and Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy (Gianenrico Rizzatti, Alberto Larghi)
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (Paraskevas Gkolfakis)
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, and Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy (Gianenrico Rizzatti, Alberto Larghi)
| | - Schalk van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium (Michiel Bronswijk, Schalk van der Merwe)
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute and University, Milan, Italy (Giuseppe Vanella, Giuseppe Dell’Anna, Paolo Giorgio Arcidiacono)
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