EUS-guided versus percutaneous biliary access in patients with obstructive jaundice due to gastric cancer

EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis

Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP. Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease. Results In total, 41 patients underwent EUS-HG and 138 patients underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64 (98%) for PTBD ( P =0.11). Clinical success was 100% for EUS-HG and 75% for PTBD ( P =0.0021). EUS-HG was associated with a lower adverse event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter procedure duration (median 60 vs. 115 minutes, P <0.0001), shorter post-procedure length of stay (median 2 vs. 4 days, P <0.0001), and fewer reinterventions (median 1 vs. 3, P <0.0001). Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.

Endoscopic Ultrasound-guided Versus Percutaneous Transhepatic Biliary Drainage After Failed ERCP: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may fail to achieve biliary drainage in 5% to 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) are alternative therapeutic options in such cases. The present meta-analysis aimed to compare the efficacy and safety of EUS-BD and PTBD for biliary decompression after failed ERCP.

METHODS

A comprehensive search of literature from inception to September 2022 was done of 3 databases for studies comparing EUS-BD and PTBD for biliary drainage after failed ERCP. Odds ratios (ORs) with 95% CIs were calculated for all the dichotomous outcomes. Continuous variables were analyzed using mean difference (MD).

RESULTS

A total of 24 studies were included in the final analysis. Technical success was comparable between EUS-BD and PTBD (OR=1.12, 0.67-1.88). EUS-BD was associated with a higher clinical success rate (OR=2.55, 1.63-4.56) and lower odds of adverse events (OR=0.41, 0.29-0.59) compared with PTBD. The incidence of major adverse events (OR=0.66, 0.31-1.42) and procedure-related mortality (OR=0.43, 0.17-1.11) were similar between the groups. EUS-BD was associated with lower odds of reintervention with an OR of 0.20 (0.10-0.38). The duration of hospitalization (MD: -4.89, -7.73 to -2.05) and total treatment cost (MD: -1355.46, -2029.75 to -681.17) were significantly lower with EUS-BD.

CONCLUSIONS

EUS-BD may be preferred over PTBD in patients with biliary obstruction after failed ERCP where appropriate expertise is available. Further trials are required to validate the findings of the study.

Gastric cancer in 2022: Is there still a role for endoscopic ultrasound?

Gastric cancer (GC) represents the fourth leading cause of cancer death worldwide and many factors can influence its development (diet, geographic area, genetic, Helicobacter pylori or Epstein-Barr virus infections). High quality endoscopy represents the modality of choice for GC diagnosis. The correct morphologic classification during a high-resolution endoscopy is fundamental for oncologic diagnosis, staging and therapeutic decisions. Since its initial introduction in clinical practice the endoscopic ultrasound (EUS) has been considered a valuable tool for tumor (T-) and lymph nodes (N-) staging also in GC, in order to establish the best therapeutic strategy for the patient (e.g., upfront surgery vs neoadjuvant treatments). EUS tools as elastography, Doppler and contrast administration can improve diagnosis mainly in case of malignant lymph node evaluation. EUS has a marginal role in disease staging but has a fundamental role in case of a pre-endoscopic resection management and in the new era of endoscopic mucosal resection or submucosal dissection as minimally invasive surgery. Diagnosis and locoregional staging of GC with EUS are a method of inarguable value for the assessment of gastric wall involvement and presence of infiltrated paragastric lymph nodes. EUS can also have a role in disease restaging in those patients who have undergone neoadjuvant treatment. EUS can also have a role in the advanced phases of the disease, in facilitating palliative, minimally-invasive treatments, such as gastroenterostomy or biliary drainages. This review intends to discuss the modern role of EUS in GC topic.

EUS-guided hepaticogastrostomy in patients with obstructive jaundice after failed or impossible endoscopic retrograde drainage: A multicenter, randomized phase II Study

Background and Objectives

Over the last two decades, EUS-guided hepaticogastrostomy (EUS-HGS) has emerged as a therapeutic alternative for patients with biliary obstruction and failed ERCP. Percutaneous transhepatic biliary drainage (PTBD) as the gold standard is associated with relevant morbidity and need for re-intervention. The aim of our work was to evaluate in a phase II study the safety and efficacy profile of EUS-HGS. A PTBD arm was considered a control group.

Patients and Methods

We conducted a prospective, randomized, noncomparative phase II study in three French tertiary centers involving patients with benign or malignant obstructive jaundice after failure of ERCP. Patients were randomized to either PTBD or EUS-HGS.

Results

Fifty-six patients (mean age 64 years) have been included between 2011 and 2015. Twenty-one underwent PTBD and thirty-five were drained using EUS-HGS. An interim analysis after the inclusion of 41 patients revealed an unexpected high 30-day morbidity rate for PTBD (13 out of 21 patients), justifying to stop randomization and inclusion in this control arm in 2013. The primary objective was reached with 10 out of the 35 EUS-HGS patients (28.6%) having observed complications (90%-level bilateral exact binomial confidence interval [CI] [16.4%-43.6%], left-sided exact binomial test to the objectified 50% unacceptable rate P = 0.0083). Both methods achieved comparable technical success rate (TSR) and clinical success rate (CSR) (TSR: PTBD 100% vs. EUS-HGS 94.3%, P = 0.28; CSR: PTBD 66.7% vs. EUS-HGS 80%, P = 0.35). Long-term follow-up showed EUS-HGS patients being at lower risk for re-intervention (relative risk = 0.47, 95% CI [0.27-0.83]).

Conclusion

In cases of ERCP failure, EUS-HGS is a valuable alternative for biliary drainage with a high TSR and CSR. PTBD is associated with an unacceptable 30-day morbidity rate, whereas EUS-HGS seems to have a decent safety profile, suggesting that it may be the treatment of choice in appropriately selected patients.

The value of endoscopic ultrasonography for differential diagnosis in obstructive jaundice of the distal common bile duct

INTRODUCTION

Obstructive jaundice is a common clinical disease of great significance; however, diagnosing it according to etiology, especially in patients with distal obstructive jaundice is difficult. The development of endoscopic ultrasonography has improved diagnostic methods. Endoscopic ultrasonography not only improves the accuracy of conventional endoscopic ultrasound technology in etiological diagnosis, but also offers several special endoscopic ultrasound technologies for diagnosing distal obstructive jaundice of the common bile duct. What's more, endoscopic ultrasonography can be used to treat distal obstructive jaundice of common bile duct.

AREAS COVERED

This review discusses the diagnostic value and applications of endoscopic ultrasonography for obstructive jaundice of the distal common bile duct.

EXPERT OPINION

This article summarizes the value of endoscopic ultrasonography in the etiological diagnosis, relevant treatment applications of distal obstructive jaundice and the limitations of endoscopic ultrasonography in some etiologies due to the lack of clear comparison with other imaging methods. We also provide new data for the future research direction of endoscopic ultrasonography in distal obstructive jaundice.

Malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer

Malignant biliary obstruction generally results from primary malignancies of the pancreatic head, bile duct, gallbladder, liver, and ampulla of Vater. Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction. The most common primaries include renal cancer, lung cancer, gastric cancer, colorectal cancer, breast cancer, lymphoma, and melanoma. They may be difficult to differentiate from primary hepato-pancreato-biliary cancer based on imaging studies, or even on biopsy. There is also no consensus on the optimal method of treatment, including the feasibility and effectiveness of endoscopic intervention or surgery. A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented. The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer. Different primaries also cause malignant biliary obstruction in different ways, including direct invasion, pancreatic or biliary metastasis, hilar lymph node metastasis, liver metastasis, and peritoneal carcinomatosis. Metastasectomy may hold promise for some types of pancreato-biliary metastases. This review aims to elucidate the current knowledge in this area, which has received sparse attention in the past. The aging population, advances in diagnostic imaging, and improved treatment options may lead to an increase in these rare occurrences going forward.

Endoscopic Ultrasound-Guided Hepaticogastrostomy: Technical Review and Tips to Prevent Adverse Events

Most patients who require biliary drainage can be treated by endoscopic retrograde cholangiopancreatography (ERCP)-guided procedures. However, ERCP can be challenging in patients with complications, such as malignant duodenal obstruction, or a surgically-altered anatomy, such as a Roux-en-Y anastomosis, which prevent advancement of the duodenoscope into the ampulla of Vater. Recently, endoscopic ultrasound (EUS)-guided biliary drainage via transhepatic or transduodenal approaches has emerged as an alternative means of biliary drainage. Typically, EUS-guided gallbladder drainage or choledochoduodenostomy can be performed via both approaches, as can EUS-guided hepaticogastrostomy (HGS). EUS-HGS, because of its transgastric approach, can be performed in patients with malignant duodenal obstruction. Technical tips for EUS-HGS have reached maturity due to device and technical developments. Although the technical success rates of EUS-HGS are high, the rate of adverse events is not low, with stent migration still being reported despite many preventive efforts. In this review, we described technical tips for EUS-HGS related to bile duct puncture, guidewire insertion, fistula dilation, and stent deployment, along with a literature review. Additionally, we provided technical tips to improve the technical success of EUS-HGS.

EUS-guided biliary drainage for difficult cannulation

EUS-guided biliary drainage (EUS-BD) has been recognized as a new alternative to failed ERCP. The alternatives for failed/impossible ERCP in cases of difficult and selective bile duct cannulation include percutaneous transhepatic BD (PTBD) with precut papillotomy. EUS-BD is reportedly more convenient than PTBD and more successful than precut papillotomy, suggesting that EUS-BD is the next step following failed/impossible ERCP.

Efficacy of endoscopic ultrasound-guided and endoscopic retrograde cholangiopancreatography-guided biliary drainage for malignant biliary obstruction: a systematic review and meta-analysis

INTRODUCTION

Endoscopic ultrasound-guided (EUS) biliary drainage was used as an alternative method for patients who failed endoscopic retrograde cholangiopancreatography (ERCP). In recent years, an increasing number of patients was treated with EUS-biliary drainage (BD), but lack of data was available to value the efficacy and safety between EUS and ERCP. Therefore, a review was needed to evaluate the similarities and differences between the two methods and explored whether EUS-guided biliary drainage could be considered as first-line treatment.

EVIDENCE ACQUISITION

We searched the Pubmed/Medline, Embase, Web of science, Google scholar, the Cochrane Library and Clinical trials of electronic databases till October 2018 for all English language. Primary outcomes to comparison included technical success, clinical success and adverse events. Secondary outcomes consisted of stent dysfunction requiring reintervention and procedure duration, Data from selected studies were collected to calculate the odds ratios (OR) and standard mean difference (SMD).

EVIDENCE SINTHESIS

We searched 469 studies and at last identified 4 eligible trials. These included a total of 428 patients, 215 in the EUS group and 213 in the ERCP group. There was no difference in technical success (OR, 0.95; 95% CI: 0.45-2.02; I2=0%), clinical success (OR, 0.87; 95% CI: 0.42-1.79; I2=0%) and adverse events between 2 procedures (OR, 0.76; 95% CI: 0.29-2.00; I2=55%) but EUS-BD consisted of lower rate of reintervention (OR, 0.30; 95% CI: 0.14-0.63; I2=0%),and fewer procedure-related adverse events in pancreatitis and cholangitis (OR, 0.14; 95% CI: 0.04-0.51; I2=0%).There was no difference in length of procedure duration, with a pooled standard mean difference of 0.26 (95% CI: -0.15 to 0.66).

CONCLUSIONS

EUS-BD and ERCP-BD in terms of relief of malignant biliary obstruction presented the similarity rate of technical success, clinical success and there is no significant difference in adverse events of two procedures. EUS-BD could be used as a substitute for ERCP-BD, even considered as first-line treatment.