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Zeng Y, Zhang JW, Yang J. Endoscopic management of infected necrotizing pancreatitis: Advancing through standardization. World J Gastroenterol 2025; 31:107451. [DOI: 10.3748/wjg.v31.i20.107451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2025] [Revised: 04/12/2025] [Accepted: 05/12/2025] [Indexed: 05/28/2025] Open
Abstract
Infected necrotizing pancreatitis (INP) remains a life-threatening complication of acute pancreatitis. Despite advancements such as endoscopic ultrasound (EUS)-guided drainage, lumen-apposing metal stents, and protocolized step-up strategies, the clinical practice remains heterogeneous, with variability in endoscopic strategies, procedural timing, device selection, and adjunctive techniques contributing to inconsistent outcomes. This review synthesizes current evidence to contribute to a structured framework integrating multidisciplinary team decision-making, advanced imaging (three-dimensional reconstruction, contrast-enhanced computed tomography/magnetic resonance imaging), EUS assessment, and biomarker-driven risk stratification (C-reactive protein, procalcitonin) to optimize patient selection, intervention timing, and complication management. Key standardization components include endoscopic assessment and procedural strategies, optimal timing of intervention, personalized approaches for complex pancreatic collections, and techniques to reduce the number of endoscopic debridements and mitigate complications. This work aims to enhance clinical outcomes, minimize practice heterogeneity, and establish a foundation for future research and guideline development in endoscopic management of INP.
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Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Obeid A, Kochhar GS. Lumen-Apposing Metal Stent for Pyloric Stricture in Crohn's Disease: A Case Report. Cureus 2025; 17:e80129. [PMID: 40190976 PMCID: PMC11971702 DOI: 10.7759/cureus.80129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2025] [Indexed: 04/09/2025] Open
Abstract
Lumen-apposing metal stents (LAMSs) are primarily used for the endoscopic drainage of pancreatic fluid collections. However, they have also been employed off-label for other indications. A limited number of case reports have described the use of LAMS in patients with Crohn's disease (CD). Here, we present a case of a patient with a long-standing history of CD and pyloric stenosis who had failed multiple endoscopic balloon dilations. Following a multidisciplinary discussion, LAMS was successfully used to treat pyloric stenosis without complications. To our knowledge, scientific data on the use of LAMS for CD-related strictures remains limited, and this case adds to the growing body of evidence in this clinical context.
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Affiliation(s)
- Ayah Obeid
- Internal Medicine, St. Luke's University Health Network, Bethlehem, USA
| | - Gursimran S Kochhar
- Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, USA
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Zafar Y, Sohail MU, Ibrahim ZS, Batool RM, Ansari I, Ahmed SZ, Saad M, Aisha E, Waqas SA, Sohail MO, Bukeirat F, Tang SJ, Ahmed R. Efficacy of Metal Stents Versus Plastic Stents for Treatment of Walled-Off Pancreatic Necrosis: A Systematic Review and Meta-Analysis. JGH Open 2025; 9:e70109. [PMID: 39902093 PMCID: PMC11788585 DOI: 10.1002/jgh3.70109] [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: 11/30/2024] [Revised: 01/10/2025] [Accepted: 01/20/2025] [Indexed: 02/05/2025]
Abstract
Background Walled-off necrosis (WON) is a potentially fatal condition best treated endoscopically with metal or plastic stents. This study compares the clinical outcomes of these stents. Methods PubMed and Cochrane were searched for trials comparing metal and plastic stents for WON. Primary outcomes were clinical and technical success. Results Seven studies with 230 metal stent patients and 226 plastic stent patients were included. Metal stents showed significantly shorter procedure times (SMD -0.80, 95% CI: -1.25 to -0.34), better 4-week clinical success (OR 1.94, 95% CI: 1.00 to 3.77), and higher procedure costs (SMD 1.38, 95% CI: 0.56 to 2.20). No significant differences were observed in hospital stay (SMD -0.05, 95% CI: -0.35 to 0.25), technical success (OR 1.45, 95% CI: 0.22 to 9.43), clinical success (OR 1.13, 95% CI: 0.54 to 2.39), interventions (SMD -0.02, 95% CI: -0.34 to 0.29), need for necrosectomy (RR 1.10, 95% CI: 0.59 to 2.04), necrosectomy sessions (SMD 0.35, 95% CI: -0.42 to 1.11), need for percutaneous drainage (RR 0.82, 95% CI: 0.36 to 1.85), stent migration (RR 0.88, 95% CI: 0.29 to 2.66), bleeding (RR 0.97, 95% CI: 0.53 to 1.75), WON recurrence (RR 1.66, 95% CI: 0.70 to 3.92), treatment failure (death) (RR 0.75, 95% CI: 0.37 to 1.53), disconnected pancreatic duct (RR 0.93, 95% CI: 0.79 to 1.11), and total cost (SMD -0.02, 95% CI: -0.29 to 0.26). Conclusion Metal stents offer shorter procedure time and better 4-week clinical success, although at a higher cost, with most clinical outcomes showing no significant differences between stent types.
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Affiliation(s)
- Yousaf Zafar
- Department of Internal MedicineUniversity of Mississippi Medical CenterJacksonUSA
| | | | | | | | - Ifrah Ansari
- Department of MedicineDow University of Health SciencesKarachiPakistan
| | - Syed Zaeem Ahmed
- Department of MedicineDow University of Health SciencesKarachiPakistan
| | - Muhammad Saad
- Department of MedicineDow University of Health SciencesKarachiPakistan
| | - Eliza Aisha
- Department of MedicineDow University of Health SciencesKarachiPakistan
| | - Saad Ahmed Waqas
- Department of MedicineDow University of Health SciencesKarachiPakistan
| | | | - Faisal Bukeirat
- Department of Digestive DiseasesUniversity of Mississippi Medical CenterJacksonUSA
| | - Shou Jiang Tang
- Department of Digestive DiseasesUniversity of Mississippi Medical CenterJacksonUSA
| | - Raheel Ahmed
- National Heart and Lung InstituteImperial College LondonLondonUK
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Chow KW, Cumpian NA, Makar R, Zargar P, Oza F, Suliman I, Eysselein V, Reicher S. Lumen-Apposing Metal Stents in the Management of Complex Pelvic Abscesses. Diagnostics (Basel) 2024; 14:2854. [PMID: 39767215 PMCID: PMC11675556 DOI: 10.3390/diagnostics14242854] [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: 11/14/2024] [Revised: 12/11/2024] [Accepted: 12/13/2024] [Indexed: 01/11/2025] Open
Abstract
BACKGROUND Lumen-apposing metal stents (LAMS) are utilized in a wide range of therapeutic gastrointestinal applications. We present our experience with LAMS-assisted drainage of complex pelvic abscesses at a large safety-net hospital. METHODS EUS-guided LAMS placements for pelvic abscesses from July 2020 to June 2024 were analyzed. Data were collected on patient demographics, procedure indications, fluid collection size, stent characteristics, stent dwell time, and complications. All cases underwent multidisciplinary review with Surgery and Interventional Radiology (IR) prior to LAMS-assisted drainage; all were deemed not amenable to drainage by IR. RESULTS Eleven patients underwent EUS-guided drainage of complex pelvic abscesses with cautery-enhanced LAMS. Diverticulitis was the most common cause of abscesses (n = 6; 55%). The average time from presentation to drainage was 7 days (1-18). The average abscess size was 7.2 cm (3.9-12.0 cm). The most common LAMS size was 15 mm × 10 mm; each was placed through the left colon and rectum with both technical and clinical success. All abscesses completely resolved with a mean stent dwell time of 28 days (17-42 days). After stent removal, the fistula was not routinely closed. No complications such as stent migration, bleeding, or perforation occurred. There were no recurrences and no patients required additional surgical or IR procedures with a mean follow-up of 25 weeks (SD 35.6). CONCLUSIONS Adequate drainage is the cornerstone of pelvic abscess management, but IR or surgical access can be challenging, with inadequate drainage and prolonged hospitalization leading to significant morbidity. In our experience, EUS-guided, LAMS-assisted drainage provides a safe and effective alternative for managing pelvic abscesses.
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Affiliation(s)
- Kenneth W. Chow
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | | | - Ranjit Makar
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
- Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Pejman Zargar
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
- Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Fouzia Oza
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
- Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Idrees Suliman
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
- Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Viktor Eysselein
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
- Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Sofiya Reicher
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
- Division of Gastroenterology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
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Takahashi K, Ohyama H, Ohno I, Kato N. Outcomes and Post-removal Course of Lumen-Apposing Metal Stent Placement for Peripancreatic Fluid Collections: A Comparative Study of Pancreatic Pseudocysts and Walled-Off Necrosis. Cureus 2024; 16:e71561. [PMID: 39553082 PMCID: PMC11565458 DOI: 10.7759/cureus.71561] [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] [Accepted: 10/11/2024] [Indexed: 11/19/2024] Open
Abstract
AIM Pancreatic fluid collections (PFCs) are common local complications of pancreatitis that may require interventional therapy. Endoscopic ultrasound (EUS)-guided transluminal drainage from the digestive tract, particularly with lumen-apposing metal stents (LAMS), is the first-line therapy due to its safety and efficacy. However, adverse events and post-removal courses remain uncertain. This study aimed to clarify the characteristics of LAMS placement and its removal, comparing pancreatic pseudocysts (PPC) and walled-off necrosis (WON). METHODS This single-center retrospective study included 23 patients who underwent transgastric LAMS placement for PFCs under EUS guidance. The patients were categorized into the PPC group (n = 14) and the WON group (n = 9). Backgrounds and clinical outcomes were analyzed and compared. RESULTS The mean procedure time was 19 minutes in the PPC group and 25 minutes in the WON group, with no significant difference (p = 0.11). The overall incidence of adverse events during LAMS placement was 14.3% in the PPC group and 33.3% in the WON group, with no significant difference (p = 0.28), but the incidence of infection of noninfected fluid collections was 0% in the PPC group and 55.5% in the WON group, significantly higher in the WON group (p = 0.0016). At the time of LAMS removal, a double-pigtail plastic stent (DPS) was replaced in 53.8% of the PPC group and 57.1% of the WON group. Within one year, 57.1% of the replaced DPS in the PPC group and 25.0% in the WON group became dislocated. There were no adverse events due to the dislocation of the replaced DPS. Adverse events occurred in one patient in each group after LAMS removal: 7.7% in the PPC group and 14.3% in the WON group (p = 0.64), which consisted of peritonitis in the PPC group and recurrent infection of fluid collection in the WON group, and both of these events occurred when the replaced DPS was still in place after LAMS removal. CONCLUSIONS Although there was no significant difference in the overall incidence of adverse events between PPC and WON, the incidence of infection after LAMS placement was significantly higher in WON. Regarding the replaced DPS, there were some cases of dislocation within one year, but there were no related adverse events. Adverse events occurred even after the removal of LAMS and replacement with DPS, so careful follow-up is required.
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Affiliation(s)
| | | | - Izumi Ohno
- Gastroenterology, Chiba University, Chiba, JPN
| | - Naoya Kato
- Gastroenterology, Chiba University, Chiba, JPN
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Singh S, Chandan S, Facciorusso A. Role of endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction. World J Gastrointest Surg 2024; 16:2369-2373. [PMID: 39220057 PMCID: PMC11362943 DOI: 10.4240/wjgs.v16.i8.2369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/15/2024] [Accepted: 06/03/2024] [Indexed: 08/16/2024] Open
Abstract
Endoscopic ultrasound-guided biliary drainage (EUS-BD) directs bile flow into the digestive tract and has been mostly used in patients with malignant biliary obstruction (MBO) where endoscopic retrograde cholangiopancreatography-guided biliary drainage was unsuccessful or was not feasible. Lumen apposing metal stents (LAMS) are deployed during EUS-BD, with the newer electrocautery-enhanced LAMS reducing procedure time and complication rates due to the inbuilt cautery at the catheter tip. EUS-BD with electrocautery-enhanced LAMS has high technical and clinical success rates for palliation of MBO, with bleeding, cholangitis, and stent occlusion being the most common adverse events. Recent studies have even suggested comparable efficacy between EUS-BD and endoscopic retrograde cholangiopancreatography as the primary approach for distal MBO. In this editorial, we commented on the article by Peng et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2024.
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Affiliation(s)
- Sahib Singh
- Department of Internal Medicine, Sinai Hospital, Baltimore, MD 21215, United States
| | - Saurabh Chandan
- Center for Interventional Endoscopy (CIE), Advent Health, Orlando, FL 32803, United States
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia 71122, Italy
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Seitz N, Meier B, Caca K, Wannhoff A. Propensity score-matched retrospective cohort study of endoscopic ultrasound-guided gastroenterostomy and enteral stenting for malignant gastric outlet. Surg Endosc 2024; 38:2078-2085. [PMID: 38438674 DOI: 10.1007/s00464-024-10745-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 01/31/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Symptomatic malignant gastric outlet obstruction (GOO) significantly reduce patients' quality of life. Endoscopic treatment involves enteral stenting or endoscopic ultrasonography to perform gastroenterostomy (EUS-GE). Aim was to compare enteral stenting with EUS-GE for endoscopic treatment of malignant GOO. METHODS We retrospectively compared enteral stenting with EUS-GE for the treatment of malignant GOO. Patients treated at our institution were identified and a propensity score matching analysis was performed. Treatment failure was the primary outcome, while the secondary endpoints were time until treatment failure, technical and clinical success rates, and adverse event rates. RESULTS Eighty-eight patients were included in the final analysis. Of whom, 44 were included in each of the two treatment groups. Treatment failure occurred significantly more frequently in the enteral stenting group (13/44) compared with the EUS-GE group (4/44; hazard ratio: 4,9; 95% CI 1.6-15.1). A Kaplan-Meier analysis revealed a median time until treatment failure of 22.0 weeks (95% CI 4.6-39.4) in the enteral stenting group compared with 76.0 weeks (95% CI 55.9-96.1) in the EUS-GE group (P = .002). No difference in technical success and clinical success was detected. Technical success was achieved in 43/44 patients (97.7%) in the enteral stenting group compared with 41/44 patients (93.2%) in the EUS-GE group, while clinical success was achieved in 32/44 (72.7%) and 35/44 (79.5%) patients, respectively. Nine adverse events were observed (9/44, 10.2%). There were no differences in 30-day adverse event rate and 30-day mortality rate. CONCLUSION EUS-GE was superior to enteral stenting in the treatment of malignant GOO in terms of treatment failure and time until treatment failure in a propensity score-matched cohort.
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Affiliation(s)
- Nadine Seitz
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Benjamin Meier
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Karel Caca
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Andreas Wannhoff
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany.
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Tian Y, Yin C, Ma Y, Fu G, Liu R, Ran H, Pan T, Xiao Y, Wen X. Lumen-apposing metal stents versus traditional self-expanding metal stents for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis. Surg Endosc 2024; 38:586-596. [PMID: 38151677 DOI: 10.1007/s00464-023-10636-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/29/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Endoscopic drainage has become the preferred treatment for pancreatic fluid collections (PFCs). There is still a lack of reliable evidence to prove which metal stent is the best choice for endoscopic ultrasound (EUS)-guided drainage of PFCs. In this study, we aimed to evaluate the efficacy and safety of lumen-apposing metal stents (LAMS) compared to traditional self-expanding metal stents (SEMS) in meta-analysis. METHODS We systematically searched PubMed, Embase, Web of Science, and Cochrane Library up to July 15, 2023. Relevant publications that compared LAMS with traditional SEMS for drainage of patients' PFCs under EUS-guidance were included. This meta-analysis assessed endpoints using Review Manager 5.3 and Stata 14.0 statistical software. RESULT Nine citations comprising 707 patients with PFCs were included. The clinical success rate of LAMS tended to be higher than that of SEMS (RR = 1.07, 95%CI [1.00, 1.15], P = 0.05). LAMS had a lower technical success rate (RR = 0.97, 95%CI [0.94, 0.99], P = 0.02) and faster procedure time (minutes) (MD = - 24.29, 95%CI [- 25.59, - 22.99], P < 0.00001) compared to SEMS. In addition, LAMS had fewer overall adverse events (RR = 0.64, 95%CI [0.48, 0.87], P = 0.004). For specific adverse events, LAMS had fewer migration (RR = 0.37, 95%CI [0.19, 0.72], P = 0.003), occlusion (RR = 0.43, 95%CI [0.22, 0.82], P = 0.01) and infection (RR = 0.38, 95%CI [0.20, 0.70], P = 0.002). There was no significant difference in bleeding and perforation between the two stents. For hospital stay (days), LAMS group was similar to SEMS group (MD = - 3.34, 95%CI [- 7.71, - 1.03], P = 0.13). Regarding recurrence, LAMS group was fewer than SEMS group (RR = 0.41, 95%CI [0.21, 0.78], P = 0.007). CONCLUSION Compared to traditional SEMS, LAMS has a higher clinical success rate, faster procedure time, fewer adverse events, similar hospital stay and lower recurrence rate in EUS-guided drainage of PFCs. LAMS is a good choice with a high technical success rate over 95%, and using a shorter length or "one-step" operation can further improve it. Richer placement experience is required for LAMS placement under EUS-guidance.
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Affiliation(s)
- Yong Tian
- Department of Gastroenterology, Chengdu First People's Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Changjie Yin
- People's Liberation Army, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yihan Ma
- Department of Gastroenterology, Chengdu First People's Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Guochuan Fu
- Department of Gastroenterology, Chengdu First People's Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Rui Liu
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Hongmei Ran
- Department of Gastroenterology, Chengdu First People's Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Tao Pan
- Department of Gastroenterology, Chengdu First People's Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Yang Xiao
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Xudong Wen
- Department of Gastroenterology, Chengdu First People's Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
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Bahdi F, Labora A, Shah S, Farooq M, Wangrattanapranee P, Donahue T, Issa D. From Scalpel to Scope: How Surgical Techniques Made Way for State-of-The-Art Endoscopic Procedures. GASTRO HEP ADVANCES 2023; 3:370-384. [PMID: 39131137 PMCID: PMC11307641 DOI: 10.1016/j.gastha.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/30/2023] [Indexed: 08/13/2024]
Abstract
The continuous evolution of endoscopic tools over the years has paved the way for minimally invasive alternatives to surgical procedures for multiple gastrointestinal conditions. While few endoscopic techniques have supplanted their surgical counterparts like percutaneous gastrostomy tubes, many have emerged as noninferior, less morbid alternatives for such diverse conditions as achalasia (peroral endoscopic myotomy), obesity (endoscopic sleeve gastroplasty), drainage of pancreatic walled off necrosis (EUS-guided cystogastrostomy), and gastric outlet obstruction (EUS-guided gastrojejunostomy). These techniques were based on surgical concepts and would not have been feasible without collaboration between surgeons and endoscopists. Such collaboration is exemplified by the antireflux fundoplication, which features combined hiatal hernia repair with transoral and incisionless fundoplication. The burgeoning armamentarium of endoscopic alternatives to traditional surgical procedures requires a multidisciplinary discussion and individually tailored treatment plans that consider patient preferences as well as the relative risks and benefits of surgical and endoscopic approaches. As technological advances give rise to ever more innovative endoscopic techniques, studies to evaluate clinical outcomes and define their role in treatment algorithms will be required.
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Affiliation(s)
- Firas Bahdi
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Amanda Labora
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sagar Shah
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Maryam Farooq
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peerapol Wangrattanapranee
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Timothy Donahue
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Danny Issa
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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On W, Ahmed W, Everett S, Huggett M, Paranandi B. Utility of interventional endoscopic ultrasound in pancreatic cancer. Front Oncol 2023; 13:1252824. [PMID: 37781196 PMCID: PMC10540845 DOI: 10.3389/fonc.2023.1252824] [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: 07/04/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Endoscopic ultrasound (EUS) has an important role in the management algorithm of patients with pancreatic ductal adenocarcinoma (PDAC), typically for its diagnostic utilities. The past two decades have seen a rapid expansion of the therapeutic capabilities of EUS. Interventional EUS is now one of the more exciting developments within the field of endoscopy. The local effects of PDAC tend to be in anatomical areas which are difficult to target and endoscopy has cemented itself as a key role in managing the clinical sequelae of PDAC. Interventional EUS is increasingly utilized in situations whereby conventional endoscopy is either impossible to perform or unsuccessful. It also adds a different dimension to the host of oncological and surgical treatments for patients with PDAC. In this review, we aim to summarize the various ways in which interventional EUS could benefit patients with PDAC and aim to provide a balanced commentary on the current evidence of interventional EUS in the literature.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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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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12
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On W, Huggett MT, Young A, Pine J, Smith AM, Tehami N, Maher B, Pereira SP, Johnson G, Paranandi B. Endoscopic ultrasound guided gastrojejunostomy in the treatment of gastric outlet obstruction: multi-centre experience from the United Kingdom. Surg Endosc 2023; 37:1749-1755. [PMID: 36217058 PMCID: PMC10017786 DOI: 10.1007/s00464-022-09692-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 09/25/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) with lumen apposing metal stents has recently emerged as a viable option, as an alternative to surgical gastrojejunostomy and endoscopic enteral stenting, for managing gastric outlet obstruction (GOO). We aim to perform a retrospective analysis of the efficacy, safety and outcomes of EUS-GJ performed at three tertiary institutions in the United Kingdom. METHODS Consecutive patients who underwent EUS-GJ between August 2018 and March 2021 were identified from a prospectively maintained database. Data were obtained from interrogation of electronic health records. RESULTS Twenty five patients (15 males) with a median age of 63 years old (range 29-80) were included for analysis. 88% (22/25) of patients had GOO due to underlying malignant disease. All patients were deemed surgically inoperable or at high surgical risk. Both technical and clinical success were achieved in 92% (23/25) of patients. There was an improvement in the mean Gastric Outlet Obstruction Scoring System scores following a technically successful EUS-GJ (2.52 vs 0.68, p < 0.01). Adverse events occurred in 2/25 patients (8%), both due to stent maldeployment necessitating endoscopic closure of the gastric defect with clips. Long-term follow-up data were available for 21 of 23 patients and the re-intervention rate was 4.8% (1/21) over a median follow-up period of 162 (range 5-474) days. CONCLUSION EUS-GJ in carefully selected patients is an effective and safe procedure when performed by experienced endoscopists.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alistair Young
- Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James Pine
- Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew M Smith
- Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nadeem Tehami
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ben Maher
- Department of Interventional Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stephen P Pereira
- Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, UK
| | - Gavin Johnson
- Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
- St James's University Hospital, 4th Floor, Bexley Wing, Beckett Street, Leeds, LS9 7TF, UK.
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13
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Kurihara H, Bunino FM, Fugazza A, Marrano E, Mauri G, Ceolin M, Lanza E, Colombo M, Facciorusso A, Repici A, Anderloni A. Endosonography-Guided Versus Percutaneous Gallbladder Drainage Versus Cholecystectomy in Fragile Patients with Acute Cholecystitis-A High-Volume Center Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1647. [PMID: 36422184 PMCID: PMC9699066 DOI: 10.3390/medicina58111647] [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: 10/02/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Acute cholecystitis is a frequent cause of admission to the emergency department, especially in old and frail patients. Percutaneous drainage (PT-GBD) and endosonographic guided drainage (EUS-GBD) could be an alternative option for relieving symptoms or act as a definitive treatment instead of a laparoscopic or open cholecystectomy (LC, OC). The aim of the present study was to compare different treatment groups. Materials and Methods: This is a five-year monocentric retrospective study including patients ≥65 years old who underwent an urgent operative procedure. A descriptive analysis was conducted comparing all treatment groups. A propensity score was estimated based on the ACS score, incorporated into a predictive model, and tested by recursive partitioning analysis. Results: 163 patients were included: 106 underwent a cholecystectomy (81 laparoscopic (LC) and 25 Open (OC)), 33 a PT-GBD and 21 EUS-GBD. The sample was categorized into three prognostic groups according to the adverse event occurrence rate. All patients treated with EUS-GBD or LC resulted in the low risk group, and the adverse event rate (AE) was 10/96 (10.4%). The AE was 4/28 (14.2%) and 21/36 (58.3%) in the middle- and high-risk groups respectively (p < 0.001). These groups included all the patients who underwent an OC or a PT-GBD. The PT-GBD group had a lower clinical success rate (55.5%) and higher RR (16,6%) when compared with other groups. Conclusions: Surgery still represents the gold standard for AC treatment. Nevertheless, EUS-GBD is a good alternative to PT-GBD in terms of clinical success, RR and AEs in all kinds of patients.
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Affiliation(s)
- Hayato Kurihara
- Emergency Surgery Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Francesca M. Bunino
- Emergency Surgery and Trauma Section, Department of Surgery, IRCCS—Humanitas Research Hospital, 20089 Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Italy
| | - Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, IRCCS—Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Enrico Marrano
- General Surgery, Hospital Universitari Parc Taulí, 08208 Sabadell, Spain
| | - Giulia Mauri
- Emergency Surgery and Trauma Section, Department of Surgery, IRCCS—Humanitas Research Hospital, 20089 Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Italy
| | - Martina Ceolin
- Emergency Surgery and Trauma Section, Department of Surgery, IRCCS—Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Ezio Lanza
- Department of Diagnostic and Interventional Radiology, IRCCS—Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, IRCCS—Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia, 71122 Foggia, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Italy
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, IRCCS—Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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14
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Kasapidis P, Mavrogenis G, Mandrekas D, Bazerbachi F. Short benign ileocolonic anastomotic strictures - management with bi-flanged metal stents: Six case reports and review of literature. World J Clin Cases 2022; 10:10162-10171. [PMID: 36246813 PMCID: PMC9561585 DOI: 10.12998/wjcc.v10.i28.10162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/19/2022] [Accepted: 08/25/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The endoscopic management of benign short post-anastomotic ileocolonic stricture (PAICS) that is refractory to primary and secondary treatment modalities remains challenging. The lumen-apposing metal stent (LAMS) is a novel device recently developed for therapeutic gastrointestinal endoscopy. LAMSs have demonstrated significantly better results with regard to stent migration than fully covered self-expandable metal stents (FCSEMSs).
CASE SUMMARY This article presents six cases of symptomatic PAICS successfully treated with a LAMS and a review of the relevant literature. We report a life-saving technique not previously documented and the use of technology to improve patient outcomes. The six patients (median age, 75 years) suffered from vomiting, constipation and recurrent abdominal pain, with symptoms starting 23-25 wk post-surgery. The median stricture length was 1.83 cm. All six patients underwent successful and uneventful bi-flanged metal stent (BFMS)-LAMS placement for benign PAICS. All patients remained asymptomatic during the three months of stent indwelling and up to a median of 7 mo after stent removal. According to the literature, the application of LAMS for PAICS is associated with a < 10% risk of migration and a < 5% risk of bleeding. Conversely, FCSEMS has a high migration rate (15%-50%).
CONCLUSION The evolving role of interventional endoscopy and the availability of LAMSs provide patients with minimally invasive treatment options, allowing them to avoid more invasive surgical interventions. The BFMS (NAGI stent) is longer and larger than the prototype AXIOS-LAMS, which should be considered in the management of short ileocolonic post-anastomotic strictures longer than 10 mm and shorter than 30 mm.
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Affiliation(s)
- Panagiotis Kasapidis
- Department of Gastroenterology and Endoscopy Unit, Central Clinic of Athens, Athens 10680, Greece
| | - Georgios Mavrogenis
- Department of Gastroenterology, Mediterraneo Hospital, Glyfada, Athens 16685, Greece
| | - Dimitrios Mandrekas
- Department of Surgery, National and Kapodistrian University of Athens, Athens 11527, Greece
- Department of Surgery, Attendant of Central Clinic of Athens, Athens 10680, Greece
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, MN 56301, United States
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15
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Endoscopic Ultrasound-Guided Gastrojejunostomy for Superior Mesenteric Artery Syndrome Secondary to Rapid Weight Loss. ACG Case Rep J 2022; 9:e00868. [PMID: 36212239 PMCID: PMC9534365 DOI: 10.14309/crj.0000000000000868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/16/2022] [Indexed: 11/06/2022] Open
Abstract
A 19-year-old man diagnosed with diffuse large B-cell lymphoma undergoing chemotherapy presented for recurrent emesis and weight loss. Imaging studies of the abdomen demonstrated features of superior mesenteric artery syndrome. The patient deferred conservative treatment options and was deemed not to be a surgical candidate. Endoscopic ultrasound-guided gastroenterostomy using a lumen-apposing metal stent was performed to bypass the obstruction. Subsequently, the patient's oral intake and weight significantly improved. The stent was removed 6 months after placement with resolution of superior mesenteric artery syndrome symptoms.
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16
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Purschke B, Bolm L, Meyer MN, Sato H. Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes. World J Gastroenterol 2022; 28:3383-3397. [PMID: 36158258 PMCID: PMC9346450 DOI: 10.3748/wjg.v28.i27.3383] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/07/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the "step-up approach". This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.
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Affiliation(s)
- Birte Purschke
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Louisa Bolm
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Max Nikolaus Meyer
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Hiroki Sato
- Department of Medicine, Asahikawa Medical University, Asahikawa 0788510, Hokkaido, Japan
- Department of Gastroenterology, Asahikawa Kosei Hospital, Asahikawa 0788211, Hokkaido, Japan
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17
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Kim BS, Yang SY, Lee WD, Song JS, Yang MA, Jung GM, Cho JW, Kim JW. Endoscopic Ultrasonography-guided Gastrojejunostomy for Patients with Gastric Outlet Obstruction and Pyloric Metal Stent Dysfunction. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2022; 79:260-264. [PMID: 35746840 DOI: 10.4166/kjg.2022.045] [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: 03/16/2022] [Revised: 04/03/2022] [Accepted: 04/19/2022] [Indexed: 06/15/2023]
Abstract
A 52-year-old woman with a gastric outlet obstruction (GOO) caused by pyloric cancer underwent pyloric endoscopic self-expandable metal stent (SEMS) insertion. She presented with abdominal distension 40 days later. The SEMS was dysfunctional, and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) was performed using an endoscopic nasobiliary drainage tube. A 16 mm×31 mm Niti-S ™ HOT SPAXUS™ (TaeWoong Medical, Gimpo, Korea) was inserted successfully between the stomach and the adjacent jejunum. After the procedure, the patient had a good oral intake for more than seven months. GOO is a mechanical obstructive condition caused by various benign and malignant conditions. Traditionally, surgical GJ and SEMS insertion have been used to treat GOOs. EUS-GJ is a feasible treatment option for patients with GOO and a pyloric metal stent dysfunction.
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Affiliation(s)
- Byung Sun Kim
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Sung Yeol Yang
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Won Dong Lee
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Jae Sun Song
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Min A Yang
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Gum Mo Jung
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Jin Woong Cho
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Ji Woong Kim
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
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18
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Fugazza A, Capogreco A, Cappello A, Nicoletti R, Da Rio L, Galtieri PA, Maselli R, Carrara S, Pellegatta G, Spadaccini M, Vespa E, Colombo M, Khalaf K, Repici A, Anderloni A. Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques. World J Gastrointest Endosc 2022; 14:250-266. [PMID: 35719902 PMCID: PMC9157691 DOI: 10.4253/wjge.v14.i5.250] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/03/2021] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Antonio Capogreco
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Annalisa Cappello
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna Bellaria-Maggiore Hospital, Bologna 40121, Italy
| | - Rosangela Nicoletti
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Leonardo Da Rio
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Piera Alessia Galtieri
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Roberta Maselli
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Gaia Pellegatta
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20072, Milan, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
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19
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McCarty TR, Thompson CC. Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy. Dig Dis Sci 2022; 67:1660-1673. [PMID: 35430698 DOI: 10.1007/s10620-022-07426-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 12/09/2022]
Abstract
The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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20
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Abstract
The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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21
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Bhakta D, de Latour R, Khanna L. Management of pancreatic fluid collections. Transl Gastroenterol Hepatol 2022; 7:17. [PMID: 35548474 PMCID: PMC9081921 DOI: 10.21037/tgh-2020-06] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/10/2021] [Indexed: 12/28/2023] Open
Abstract
Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).
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Affiliation(s)
- Dimpal Bhakta
- New York University School of Medicine, New York, USA
| | | | - Lauren Khanna
- New York University School of Medicine, New York, USA
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22
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Tarantino I, Sinagra E, Binda C, Fugazza A, Amato A, Maida M, Lisotti A, Crinò SF, Aragona G, Fabbri C, Anderloni A, on behalf of the i-EUS Group. Perceived Feasibility of Endoscopic Ultrasound-Guided Gastroenteric Anastomosis: An Italian Survey. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:532. [PMID: 35454371 PMCID: PMC9027201 DOI: 10.3390/medicina58040532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 12/18/2022]
Abstract
Background and Objectives: Endoscopic ultrasound-guided gastroenteric anastomosis (EUS-GEA) using lumen-apposing metal stents (LAMS) is emerging as a minimally invasive alternative to surgery across several indications. The aim of this survey is to investigate the perceived feasibility of this technique nationwide, within a working group skilled in interventional endosonography. Materials and Methods: Endoscopists were asked to answer to 49 items on a web-based questionnaire about expertise, peri- and intra-procedural aspects in the three main settings of EUS-GEA performance, budget/refund, and future perspectives. Statistical analysis was performed through SPSS® (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Results: Sixty endosonographers belonging to forty Italian centers were I-EUS app users and were all invited to participate. In total, 29 participants from 24 Italian centers completed the survey. All the participants were endosonographers with a broad range of experience both in the field of EUS (only 10.3% with more than 20 years of experience) and duodenal stenting (only 6.9% placed more than 10 stents in 2020), whereas 86.2% also performed ERCP. A total of 27.6% of participants performed EUS-GEA (3.4% more than 20 during their career); on the other hand, 79.3% of participants routinely performed drainage of peri-pancreatic fluid collections, 62.1% performed biliary drainage, and 62.1% performed gallbladder drainage with LAMS. A total of 89.7% of participants thought that EUS-GEA could be useful in their daily clinical practice, with 100% concluding that this procedure will need to be performed in referral centers in the near future; however, in 55.2% of cases, organizational obstacles may occur and affect the diffusion of the procedure. With regard to indications: 44.8% of participants performed the procedure with palliative intent for malignant indication (96.6% pancreatic adenocarcinoma), and 13.6% also for benign indication. A total of 20.7% of participants experienced adverse events (none severe or fatal, 66.6% moderate). A total of 62.1% of participants considered the procedure technically challenging, although 82.8% considered the risk of adverse events acceptable when considering the benefit. Conclusions: To our knowledge, this is the first survey assessing the perceived feasibility of EUS-guided anastomoses after its advent. There are currently wide variations in practice nationwide, which demonstrate a need to define technical, qualitative, and peri-procedural requirements to carry out this procedure. Therefore, a standardization of these requirements is needed in order to overcome the technical, economical, and organizational obstacles relative to its diffusion.
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Affiliation(s)
- Ilaria Tarantino
- Department of Diagnostic and Therapeutic Services, Endoscopy Service, IRCCS-ISMETT, 90100 Palermo, Italy;
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto G. Giglio, Contrada Pietrapollastra Pisciotto, Cefalù, 90015 Palermo, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 47121 Forli, Italy; (C.B.); (C.F.)
| | - Alessandro Fugazza
- Humanitas Clinical and Research Center IRCCS, Gastroenterology & Endoscopy Department, 20089 Rozzano, Italy;
| | - Arnaldo Amato
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, 22100 Como, Italy;
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy;
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, 40026 Imola, Italy;
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy;
| | - Giovanni Aragona
- Gastroenterology and Hepatology Unit, Ospedale Civile, Sitodell’azienda AUSL di Piacenza, 29121 Piacenza, Italy;
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 47121 Forli, Italy; (C.B.); (C.F.)
| | - Andrea Anderloni
- Unità Operativa Complessa di Gastroenterologia ed Endoscopia Digestiva, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
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Spadaccini M, Binda C, Fugazza A, Repici A, Tarantino I, Fabbri C, Cugia L, Anderloni A, on behalf of the Interventional Endoscopy & Ultra Sound (I-EUS) Group. Informed Consent for Endoscopic Biliary Drainage: Time for a New Paradigm. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:331. [PMID: 35334507 PMCID: PMC8951173 DOI: 10.3390/medicina58030331] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is considered as the first option in the management of malignant biliary obstruction. In case of ERCP failure, percutaneous transhepatic biliary drainage (PTBD) has been conventionally considered as the preferred rescue strategy. However, the use of endoscopic ultrasound (EUS) for biliary drainage (EUS-BD) has proved similarly high rates of technical success, when compared to PTBD. As a matter of fact, biliary drainage is maybe the most evident paradigm of the increasing interconnection between ERCP and EUS, and obtaining an adequate informed consent (IC) is an emerging issue. The aim of this commentary is to discuss the reciprocal roles of ERCP and EUS for malignant biliary obstruction, in order to provide a guide to help in developing an appropriate informed consent reflecting the new biliopancreatic paradigm.
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Affiliation(s)
- Marco Spadaccini
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Milan, Italy; (A.F.); (A.R.); (A.A.)
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
| | - Cecilia Binda
- Digestive Endoscopy and Gastroenterology Unit, Department of Gastroenterology, AUSL Romagna, Morgagni-Pierantoni Hospital and Bufalini Hospital, 47100 Forli, Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Milan, Italy; (A.F.); (A.R.); (A.A.)
| | - Alessandro Repici
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Milan, Italy; (A.F.); (A.R.); (A.A.)
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy
| | - Ilaria Tarantino
- Digestive Endoscopy and Gastroenterology Unit, Department of Gastroenterology, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IsMeTT/UPMC), 90127 Palermo, Italy;
| | - Carlo Fabbri
- Digestive Endoscopy and Gastroenterology Unit, Department of Gastroenterology, AUSL Romagna, Morgagni-Pierantoni Hospital and Bufalini Hospital, 47100 Forli, Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Luigi Cugia
- Gastroenterology and Digestive Endoscopy Department, Azienda Ospedaliero Universitaria Sassari, 07100 Sassari, Italy;
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, 20089 Rozzano, Milan, Italy; (A.F.); (A.R.); (A.A.)
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Zhang Y, Yuan EY, Peng M, Ding SX, Wang ZQ. Progress in research of minimally invasive therapy of local complications of acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2021; 29:1349-1354. [DOI: 10.11569/wcjd.v29.i23.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis is an inflammatory disease of the pancreas that can be life-threatening. Patients with severe acute pancreatitis require further rescue treatment in the intensive care unit. In recent years, treatment of local complications of acute pancreatitis has undergone considerable changes, including multidisciplinary team mode and individualized treatment scheme, and traditional open surgery has been gradually replaced by minimally invasive treatment. This article summarizes the progress in research on minimally invasive therapy of the local complications of acute pancreatitis in recent years.
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Affiliation(s)
- Ying Zhang
- Intensive Care Unit, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Er-Yan Yuan
- Intensive Care Unit, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Min Peng
- Intensive Care Unit, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Shao-Xue Ding
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Zhi-Qiang Wang
- Intensive Care Unit, Tianjin Medical University General Hospital, Tianjin 300052, China
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25
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Pinto S, Bellizzi S, Badas R, Canfora ML, Loddo E, Spada S, Khalaf K, Fugazza A, Bergamini S. Direct Endoscopic Necrosectomy: Timing and Technique. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121305. [PMID: 34946249 PMCID: PMC8707414 DOI: 10.3390/medicina57121305] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/12/2022]
Abstract
Walled-off pancreatic necrosis (WOPN) is one of the local complications of acute pancreatitis (AP). Several interventional techniques have been developed over the last few years. The purpose of this narrative review is to explore such methodologies, with specific focus on endoscopic drainage and direct endoscopic necrosectomy (DEN), through evaluation of their indications and timing for intervention. Findings indicated how, after the introduction of lumen-apposing metal stents (LAMS), DEN is becoming the favorite technique to treat WOPN, especially when large solid debris or infection are present. Additionally, DEN is associated with a lower adverse events rate and hospital stay, and with improved clinical outcome.
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Affiliation(s)
- Sergio Pinto
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
- Correspondence: ; Tel.: +39-07051096423
| | - Saverio Bellizzi
- Medical Epidemiologist, Independent Consultant, 1202 Geneva, Switzerland;
| | - Roberta Badas
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Maria Laura Canfora
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Erica Loddo
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Simone Spada
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milano, Italy;
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital-IRCCS, 20089 Rozzano, Italy;
| | - Silvio Bergamini
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
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26
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Dolan RD, McCarty TR, Papke DJ, Thompson CC. Drainage of gastric intramural abscesses using lumen-apposing metal stents. VideoGIE 2021; 6:407-409. [PMID: 34527838 PMCID: PMC8430045 DOI: 10.1016/j.vgie.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Russell D Dolan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David James Papke
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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27
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Cominardi A, Tamanini G, Brighi N, Fusaroli P, Lisotti A. Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasound-guided gastroentero-anastomosis. World J Gastrointest Oncol 2021; 13:1086-1098. [PMID: 34616514 PMCID: PMC8465451 DOI: 10.4251/wjgo.v13.i9.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/16/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by postprandial vomiting, abdominal pain, bloating and, in advanced cases, by weight loss secondary to inadequate oral intake. This clinical entity may be caused by mechanical obstruction, either benign or malignant, or by motility disorders. In this review we will focus on malignant GOO and on its endoscopic ultrasound (EUS)-guided palliative treatment. The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas; other causes include duodenal or ampullary neoplasms, gastric lymphomas, retroperitoneal lymphadenopathies and, more infrequently, gallbladder and bile duct cancers. Surgery represents the treatment of choice when radical and curative resection is potentially feasible; if the malignant cause is not likely to be completely resected, palliative treatments should be proposed. Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent. Both treatments are effective; however, endoscopic stent placement is less invasive and it is associated with good short-term results, while surgery provides longer-lasting effects with a lower frequency of reintervention. In the last few years, EUS-guided gastroenterostomy (GE) has been proposed as palliative treatment for malignant GOO. This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction, through the deployment of a lumen-apposing metal stent under EUS-view. EUS-GE has the advantage of being as minimally invasive as enteral stent placement, and of guaranteeing long-term results similar to those of surgery.
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Affiliation(s)
- Anna Cominardi
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Giacomo Tamanini
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Nicole Brighi
- Department of Medical Oncology, Istituto Scientifico Romagnolo Per Lo Studio Dei Tumori “Dino Amadori” (IRST) IRCCS, Meldola 47014, FC, Italy
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, University of Bologna/Hospital of Imola, Bologna 40121, Italy
| | - Andrea Lisotti
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
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28
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Pawa R, Pleasant T, Tom C, Pawa S. Endoscopic ultrasound-guided biliary drainage: Are we there yet? World J Gastrointest Endosc 2021; 13:302-318. [PMID: 34512878 PMCID: PMC8394188 DOI: 10.4253/wjge.v13.i8.302] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/14/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.
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Affiliation(s)
- Rishi Pawa
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Troy Pleasant
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Chloe Tom
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, United States
| | - Swati Pawa
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, United States
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29
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Takeda T, Sasaki T, Okamoto T, Sasahira N. Endoscopic Double Stenting for the Management of Combined Malignant Biliary and Duodenal Obstruction. J Clin Med 2021; 10:jcm10153372. [PMID: 34362153 PMCID: PMC8347422 DOI: 10.3390/jcm10153372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/25/2021] [Accepted: 07/28/2021] [Indexed: 12/21/2022] Open
Abstract
Periampullary cancers are often diagnosed at advanced stages and can cause both biliary and duodenal obstruction. As these two obstructions reduce patients’ performance status and quality of life, appropriate management of the disease is important. Combined malignant biliary and duodenal obstruction is classified according to the location and timing of the duodenal obstruction, which also affect treatment options. Traditionally, surgical bypass (gastrojejunostomy and hepaticojejunostomy) has been performed for the treatment of unresectable periampullary cancer. However, it has recently been substituted by less invasive endoscopic procedures due to its high morbidity and mortality. Thus, endoscopic double stenting (transpapillary stenting and enteral stenting) has become the current standard of care. Limitations of transpapillary stenting include its technical difficulty and the risk of duodenal-biliary reflux. Recently, endoscopic ultrasound-guided procedures have emerged as a novel platform and have been increasingly utilized in the management of biliary and duodenal obstruction. As the prognosis of periampullary cancer has improved due to recent advances in chemotherapy, treatment strategies for biliary and duodenal obstruction are becoming more important. In this article, we review the treatment strategies for combined malignant biliary and duodenal obstruction based on the latest evidence.
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Affiliation(s)
| | - Takashi Sasaki
- Correspondence: ; Tel.: +81-3-3520-0111; Fax: +81-3-3520-0141
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30
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Stefanovic S, Draganov PV, Yang D. Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction. World J Gastrointest Surg 2021; 13:620-632. [PMID: 34354796 PMCID: PMC8316851 DOI: 10.4240/wjgs.v13.i7.620] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/11/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Gastric outlet obstruction (GOO) is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum. GOO can be caused by either benign or malignant etiologies, often resulting in early satiety, nausea, vomiting and poor oral intake. GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies. Traditional treatment options for GOO can be broadly divided into surgical [surgical gastrojejunostomy (GJ)] and endoscopic interventions (dilation and/or placement of luminal self-expanding metal stents). While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting, it has also been associated with a higher rate of adverse events. Furthermore, many patients with advanced metastatic disease are not good surgical candidates. More recently, endoscopic ultrasound (EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches. This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.
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Affiliation(s)
- Sebastian Stefanovic
- Department of Gastroenterology and Hepatology, University Medical Center Ljubljana, Ljubljana 1000, Slovenia
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, Gainesville, FL 32608, United States
| | - Dennis Yang
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, Gainesville, FL 32608, United States
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Endoscopic Management of Refractory Benign Esophageal Strictures. Dysphagia 2021; 36:504-516. [PMID: 33710389 DOI: 10.1007/s00455-021-10270-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/13/2021] [Indexed: 12/13/2022]
Abstract
Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.
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32
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Feasibility and patency of echoendoscopic anastomoses with lumen apposing metal stents depending on the gastrointestinal segment involved. Sci Rep 2021; 11:3992. [PMID: 33597612 PMCID: PMC7889646 DOI: 10.1038/s41598-021-83618-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/02/2021] [Indexed: 02/07/2023] Open
Abstract
EUS-guided anastomoses with LAMS have emerged as a therapeutic option for patients with obstruction of the digestive tract. However, the long-term permeability of these anastomoses remains unknown. Most of the published cases involve the gastric wall and experience in distal obstruction is limited to few case reports. We review our series of patients treated with LAMS for gastrointestinal obstruction and describe the technical success according to the anastomotic site and the long-term follow-up in those cases in which the stent migrated spontaneously or was removed. Out of 30 cases treated with LAMS, EUS-guided anastomosis did not involve the gastric wall in 6 patients. These procedures were technically more challenging as two failures were recorded (2/6, 33%) while technical success was achieved in 100% of the cases in which the stent was placed through the gastric wall. In two of the patients, one with entero-enteric and another with recto-colic anastomosis, stent removal after spontaneous displacement was followed by long term permeability of the EUS-guided anastomosis (172 and 234 days respectively). In a EUS-guided gastroenterostomy the stent was removed at 118 days, but closure of the fistula was confirmed 26 days later. Our experience suggests that LAMS placement between bowel loops is feasible and might allow the creation of an anastomosis with long-term patency. As compared to LAMS placement between bowel loops, when LAMS are placed through the gastric wall, removal of the LAMS seems to lead to closure of the fistula.
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Troncone E, Fugazza A, Cappello A, Del Vecchio Blanco G, Monteleone G, Repici A, Teoh AYB, Anderloni A. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol 2021. [PMID: 32390697 DOI: 10.3748/wjg.v26.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome "Tor Vergata", Napoli 80129, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome "Tor Vergata", Napoli 80129, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong 999077, China
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy.
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Anderloni A, Fugazza A, Spadaccini M, Colombo M, Gabbiadini R, Siracusano LV, Pressiani T, Repici A. Single-session EUS-guided gastroenterostomy and hepaticogastrostomy using dedicated metal stents (with videos). Endosc Ultrasound 2021; 10:214-215. [PMID: 33463553 PMCID: PMC8248308 DOI: 10.4103/eus.eus_60_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Andrea Anderloni
- Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS,Rozzano, Italy
| | - Alessandro Fugazza
- Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Marco Spadaccini
- Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Matteo Colombo
- Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Roberto Gabbiadini
- Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Licia Vanessa Siracusano
- Department of Medical Oncology and Hematology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy
| | - Tiziana Pressiani
- Department of Medical Oncology and Hematology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy
| | - Alessandro Repici
- Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
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Chandrasekhara V, Barthet M, Devière J, Bazerbachi F, Lakhtakia S, Easler JJ, Peetermans JA, McMullen E, Gjata O, Gourlay ML, Abu Dayyeh BK. Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis. Endosc Int Open 2020; 8:E1639-E1653. [PMID: 33140020 PMCID: PMC7584468 DOI: 10.1055/a-1243-0092] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off pancreatic necrosis (WON). Recent studies suggested greater adverse event (AE) rates with LAMS for WON. We conducted a systematic review and meta-analysis to compare the safety and efficacy of LAMS with double-pigtail plastic stents (DPPS) for endoscopic drainage of WON. The primary aim was to evaluate stent-related AEs. Methods In October 2019, we searched the Ovid (Embase, MEDLINE, Cochrane) and Scopus databases for studies assessing a specific LAMS or DPPS for WON drainage conducted under EUS guidance. Safety outcomes were AE rates of bleeding, stent migration, perforation, and stent occlusion. Efficacy outcomes were WON resolution and number of procedures needed to achieve resolution. A subanalysis including non-EUS-guided cases was performed. Results Thirty studies including one randomized controlled trial (total 1,524 patients) were analyzed. LAMS were associated with similar bleeding (2.5 % vs. 4.6 %, P = 0.39) and perforation risk (0.5 % vs. 1.1 %, P = 0.35) compared to DPPS. WON resolution (87.4 % vs. 87.5 %, P = 0.99), number of procedures to achieve resolution (2.09 vs. 1.88, P = 0.72), stent migration (5.9 % vs. 6.8 %, P = 0.79), and stent occlusion (3.8 % vs. 5.2 %, P = 0.78) were similar for both groups. Inclusion of non-EUS-guided cases led to significantly higher DPPS bleeding and perforation rates. Conclusions LAMS and DPPS were associated with similar rates of AEs and WON resolution when limiting analysis to EUS-guided cases. Higher bleeding rates were seen in historical studies of DPPS without EUS guidance. Additional high-quality studies of WON treatment using consistent outcome definitions are needed.
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Affiliation(s)
- Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Marc Barthet
- Service d'hépato-gastroentérologie, Hôpital Nord, Chemin des Bourrely, Marseille, France
| | | | - Fateh Bazerbachi
- Division of Gastroenterology, Interventional Endoscopy Program, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Sundeep Lakhtakia
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Jeffrey J. Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, United States
| | - Joyce A. Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Margaret L. Gourlay
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Hindryckx P, Degroote H. Lumen-apposing metal stents for approved and off-label indications: a single-centre experience. Surg Endosc 2020; 35:6013-6020. [PMID: 33051767 DOI: 10.1007/s00464-020-08090-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 10/03/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND STUDY AIMS Lumen-apposing stents (LAMS) are approved to treat peripancreatic collections and for gallbladder and bile duct drainage. Over the last years, LAMS have also been used for off-label indications including gastrojejunostomy, gastro-gastrostomy and drainage of postsurgical collections. We aimed to analyze indications, technical/clinical success rates and complications of all LAMS placed over the last 2 years. PATIENTS AND METHODS Data from 61 consecutive LAMS (Hot Axios, Boston Scientific) in 57 patients were analyzed. Technical success was defined as successful deployment of the LAMS in the desired position. Clinical success was defined as follows: for pancreatic collections: resolution without the need for non-endoscopic interventions; for choledochoduodenostomy: ≥ 50% drop in baseline serum bilirubin within 2 weeks AND patient can receive chemotherapy if indicated; for gastrojejunostomy: resolution of gastric outlet obstruction and successful re-initiation of oral intake; for gastro-gastrostomy: successful endoscopic access to the excluded stomach; for gallbladder or postsurgical collection drainage: resolution of sepsis. RESULTS Indications were drainage of peripancreatic collections in 24 cases (39.3%), choledochoduodenostomy in 13 (21.3%), gastrojejunostomy in 6 (9.8%), gastro-gastrostomy in 13 (21.3%), gallbladder drainage in 1 (1.6%) and postsurgical collection drainage in 4 (6.6%). Overall technical and clinical success rates were high (57/61; 93.4% and 54/61; 88.5%, respectively). Clinical success rate for non-approved indications was 95.6% (22/23 cases). Complications occurred in 13 patients (21.3%, 4 serious). CONCLUSIONS LAMS are increasingly used in interventional endoscopy. In our cohort, more than one third of LAMS are placed for off-label indications, with a high success rate and acceptable complication rate.
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Affiliation(s)
- Pieter Hindryckx
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Helena Degroote
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Fugazza A, Colombo M, Cappello A, Nappo G, Zerbi A, Repici A, Anderloni A. Endoscopic ultrasound guided gastroenterostomy for efferent jeunal loop obstruction in a patient with previous pancreaticoduodenectomy and ascites. Endosc Int Open 2020; 8:E1435-E1436. [PMID: 33015348 PMCID: PMC7508657 DOI: 10.1055/a-1221-5183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Via Manzoni 56, 20089 Rozzano (Milano), Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Via Manzoni 56, 20089 Rozzano (Milano), Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Via Manzoni 56, 20089 Rozzano (Milano), Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center – IRCCS, Via Manzoni 56, 20089 Rozzano (Milano), Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center – IRCCS, Via Manzoni 56, 20089 Rozzano (Milano), Italy,Humanitas University, Department of Biomedical Sciences, Pieve Emanuele (MI) Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Via Manzoni 56, 20089 Rozzano (Milano), Italy,Humanitas University, Department of Biomedical Sciences, Pieve Emanuele (MI) Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center – IRCCS, Via Manzoni 56, 20089 Rozzano (Milano), Italy
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Sharma P, McCarty TR, Chhoda A, Costantino A, Loeser C, Muniraj T, Ryou M, Thompson CC. Alternative uses of lumen apposing metal stents. World J Gastroenterol 2020; 26:2715-2728. [PMID: 32550749 PMCID: PMC7284179 DOI: 10.3748/wjg.v26.i21.2715] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.
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Affiliation(s)
- Prabin Sharma
- Department of Gastroenterology and Hepatology, Yale-New Haven Health-Bridgeport Hospital, Bridgeport, CT 06610, United States
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Ankit Chhoda
- Department of Internal Medicine, Yale-New Haven Health-Bridgeport Hospital, Bridgeport, CT 06708, United States
| | - Antonio Costantino
- Department of Gastroenterology and Hepatology, Yale-New Haven Health-Bridgeport Hospital, Bridgeport, CT 06610, United States
| | - Caroline Loeser
- Department of Gastroenterology and Hepatology, Yale-New Haven Health-Bridgeport Hospital, Bridgeport, CT 06610, United States
| | - Thiruvengadam Muniraj
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
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Fugazza A, Colombo M, Repici A, Anderloni A. Endoscopic Ultrasound-Guided Gallbladder Drainage: Current Perspectives. Clin Exp Gastroenterol 2020; 13:193-201. [PMID: 32523368 PMCID: PMC7237126 DOI: 10.2147/ceg.s203626] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/13/2020] [Indexed: 12/15/2022] Open
Abstract
According to the recently updated Tokyo Guidelines, laparoscopic cholecystectomy still represents the gold standard for the treatment of acute cholecystitis. However, fragile patients, due to comorbidities or poor clinical conditions, have a high surgical risk. In such cases, percutaneous or endoscopic gallbladder drainage is considered the treatment of choice. In particular, endoscopic ultrasound-guided gallbladder drainage with the placement of specifically designed stents is now considered an alternative option. In addition, the opening of an access door to the lumen of the gallbladder could offer new opportunities for the endoscopic treatment of gallbladder diseases. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the endoscopic ultrasound-guided gallbladder drainage.
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Affiliation(s)
- Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy.,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy.,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy
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40
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Endoscopic gastrointestinal anastomoses with lumen-apposing metal stents: predictors of technical success. Surg Endosc 2020; 35:1997-2004. [PMID: 32358692 DOI: 10.1007/s00464-020-07594-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Lumen-apposing metal stents (LAMS) may be inserted to create gastrointestinal anastomoses under endoscopic ultrasound (EUS) guidance. This new technique has mostly been evaluated as treatment for gastric outlet obstruction (GOO), especially of malignant origin. Technical success was high in the few and small available studies. Aim of this study was to report our experience with this technique and to identify predictors of success in the setting of a large teaching hospital in Germany. METHODS All subsequent patients who underwent EUS-guided gastrointestinal anastomosis with LAMS from 02/2016 to 08/2019 were included. We performed a retrospective chart analysis including technical procedural details, basic demographic, and health characteristics. Technical success was defined as successful insertion of LAMS. In patients with GOO, the GOO Scoring System was used; an improvement ≥ 1 point was defined as clinical success. RESULTS Thirty-five patients (22 female, median age: 79 years) were included. Indication for the anastomosis was malignant GOO in 33 patients. In ten patients LAMS was inserted over a guidewire, in 22 patients direct puncture with the electrocautery delivery system of LAMS was performed, and other techniques were used in two patients. Technical success rate was 80.0%. Adverse events occurred in 14.3%. Clinical success rate was 74.3%. Technical success increased and procedure time decreased significantly during the study period. Distance between the two lumina connected with LAMS was significantly shorter (median: 9 mm) in patients with technical success compared to those without (median: 20 mm, P = 0.004). This distance was identified as predictor of success on multivariate analysis. CONCLUSIONS EUS-guided gastrointestinal anastomosis with LAMS is an emerging technique. Its success mainly depends on the distance between the two lumina that are going to be connected by the LAMS and is influenced by the endoscopist's experience.
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Troncone E, Fugazza A, Cappello A, Del Vecchio Blanco G, Monteleone G, Repici A, Teoh AYB, Anderloni A. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol 2020. [PMID: 32390697 DOI: 10.3748/wjg.v26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome "Tor Vergata", Napoli 80129, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome "Tor Vergata", Napoli 80129, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong 999077, China
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy.
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42
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Troncone E, Fugazza A, Cappello A, Blanco GDV, Monteleone G, Repici A, Teoh AYB, Anderloni A. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol 2020; 26:1847-1860. [PMID: 32390697 PMCID: PMC7201143 DOI: 10.3748/wjg.v26.i16.1847] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/06/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023] Open
Abstract
Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients’ survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Napoli 80129, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Napoli 80129, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong 999077, China
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
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43
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Leung Ki EL, Napoleon B. EUS-specific stents: Available designs and probable lacunae. Endosc Ultrasound 2019; 8:S17-S27. [PMID: 31897375 PMCID: PMC6896438 DOI: 10.4103/eus.eus_50_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/08/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- En-Ling Leung Ki
- Department of Hepato-Gastroenterology, Ramsay Private Hospital Jean-Mermoz, Lyon, France.,Department of Hepato-Gastroenterology, La Tour Hospital, Geneva, Switzerland
| | - Bertrand Napoleon
- Department of Hepato-Gastroenterology, Ramsay Private Hospital Jean-Mermoz, Lyon, France
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Wang G, Liu X, Wang S, Ge N, Guo J, Sun S. Endoscopic Ultrasound-guided Gastroenterostomy: A Promising Alternative to Surgery. J Transl Int Med 2019; 7:93-99. [PMID: 31637179 PMCID: PMC6795053 DOI: 10.2478/jtim-2019-0021] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Recently, with the advancement of techniques, endoscopic ultrasound-guided therapies have shown distinct advantages, especially in relieving benign and malignant gastric outlet obstruction (GOO), as well as in postoperative pancreaticobiliary diseases. Herein, we present five currently used approaches in endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumenapposing biflanged metal stents (LAMS), along with several examples of LAMS-based EUS treatment of pancreaticobiliary diseases. Compared with traditional treatment methods, EUS-guided procedures have - to some degree - shown higher success rates, both technical and clinical. Moreover, EUS-guided therapies reduce the risk of multiple surgical adverse events, including delayed gastric emptying, prolonged hospital stay, increased costs, and delay in cancer treatment. Particularly in terms of postoperative pancreaticobiliary diseases, EUS-guided therapy has assumed an essential role as a treatment option in cases where traditional methods are difficult to perform. Nevertheless, EUS-guided gastrointestinal procedures are still relatively new, with some clinical failures, and additional prospective clinical trials are warranted.
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Affiliation(s)
- Guoxin Wang
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Xiang Liu
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Sheng Wang
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Nan Ge
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Jintao Guo
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Siyu Sun
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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45
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Anderloni A, Troncone E, Fugazza A, Cappello A, Del Vecchio Blanco G, Monteleone G, Repici A. Lumen-apposing metal stents for malignant biliary obstruction: Is this the ultimate horizon of our experience? World J Gastroenterol 2019; 25:3857-3869. [PMID: 31413524 PMCID: PMC6689812 DOI: 10.3748/wjg.v25.i29.3857] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/20/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUS-guided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and EC-LAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.
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Affiliation(s)
- Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan 20089, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome 00133, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan 20089, Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan 20089, Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome 00133, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan 20089, Italy
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas University, Milan 20089, Italy
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Pérez-Cuadrado Robles E, Prat F, Deprez PH. Endoscopic ultrasound-guided drainage with lumen-apposing metal stents: a good safety profile also in the long term? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:416-418. [PMID: 31081671 DOI: 10.17235/reed.2019.6348/2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Lumen-apposing metal stents (LAMSs) have been specifically designed for the endoscopic drainage of pancreatic fluid collections and walled-off necrosis. Lately, LAMS indications have expandedto other anastomoses, and these stents have proven to be effective in multiple situations. Safety data for this device are still limited, most studies to date being focused on intraoperative complications and not long-term issues. There are little data regarding the best timing for removal and the risks associated in leaving them in place for long duration. In addition, not all the procedure-related complications have the same clinical impact, and the settings in which LAMS have been used are heterogeneous, leading to different safety profiles and outcomes. A wide consensus on the definition of complications and a list of key performance measures for LAMS placement seems mandatory to allow for a robust assessment of their long-term outcomes.
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Affiliation(s)
| | | | - Pierre H Deprez
- Gastroenterology, Cliniques universitaires Saint-Luc, Belgium
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Leung Ki EL, Napoleon B. Endoscopic ultrasound-guided biliary drainage: A change in paradigm? World J Gastrointest Endosc 2019; 11:345-353. [PMID: 31205595 PMCID: PMC6556485 DOI: 10.4253/wjge.v11.i5.345] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/11/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been developed as an alternative means of biliary drainage for malignant biliary obstruction (MBO). Compared to percutaneous transhepatic biliary drainage, EUS-BD offers effective internal drainage in a single session in the event of failed endoscopic retrograde cholangiopancreatography and has fewer adverse events (AE). In choosing which technique to use for EUS-BD, a combination of factors appears to be important in decision-making; technical expertise, the risk of AE, and anatomy. With the advent of novel all-in-one EUS-BD specific devices enabling simpler and safer techniques, as well as the growing experience and training of endosonographers, EUS-BD may potentially become a first-line technique in biliary drainage for MBO.
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Affiliation(s)
- En-Ling Leung Ki
- Department of Gastroenterology, Jean Mermoz Private Hospital, 55 avenue Jean Mermoz, Lyon 69008, France
| | - Bertrand Napoleon
- Department of Gastroenterology, Jean Mermoz Private Hospital, 55 avenue Jean Mermoz, Lyon 69008, France
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