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Troncone E, Amendola R, Moscardelli A, De Cristofaro E, De Vico P, Paoluzi OA, Monteleone G, Perez-Miranda M, Del Vecchio Blanco G. Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:633. [PMID: 38674279 PMCID: PMC11052411 DOI: 10.3390/medicina60040633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
In recent years, therapeutic endoscopy has become a fundamental tool in the management of gallbladder diseases in light of its minimal invasiveness, high clinical efficacy, and good safety profile. Both endoscopic transpapillary gallbladder drainage (TGBD) and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) provide effective internal drainage in patients with acute cholecystitis unfit for cholecystectomy, avoiding the drawbacks of external percutaneous gallbladder drainage (PGBD). The availability of dedicated lumen-apposing metal stents (LAMS) for EUS-guided transluminal interventions contributed to the expansion of endoscopic therapies for acute cholecystitis, making endoscopic gallbladder drainage easier, faster, and hence more widely available. Moreover, EUS-GBD with LAMS opened the possibility of several cholecystoscopy-guided interventions, such as gallstone lithotripsy and clearance. Finally, EUS-GBD has also been proposed as a rescue drainage modality in malignant biliary obstruction after failure of standard techniques, with encouraging results. In this review, we will describe the TBGD and EUS-GBD techniques, and we will discuss the available data on clinical efficacy in different settings in comparison with PGBD. Finally, we will comment on the future perspectives of EUS-GBD, discussing the areas of uncertainty in which new data are more strongly awaited.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Rosa Amendola
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Elena De Cristofaro
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Pasquale De Vico
- Department of Anaesthesia, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Manuel Perez-Miranda
- Department of Gastroenterology and Hepatology, University Hospital Rio Hortega, 47012 Valladolid, Spain
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Rimbaş M, Tripodi G, Rizzatti G, Larghi A. Endoscopic ultrasound in the management of acute cholecystitis: Practical review. Dig Endosc 2023; 35:809-818. [PMID: 37253177 DOI: 10.1111/den.14605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/29/2023] [Indexed: 06/01/2023]
Abstract
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged over the last years as an alternative procedure to percutaneous drainage (PT)-GBD in patients with acute cholecystitis (AC) at high surgical risk. This process has been driven by the advent of lumen-apposing metal stents (LAMS) with electrocautery-enhanced capability, which has rendered the drainage procedure easier to accomplish and safer. Studies and meta-analyses have proven the superiority of EUS-GBD over PT-GBD in high-surgical-risk patients with AC. Little evidence exists in the same setting that EUS-GBD compares equally with laparoscopic cholecystectomy (LC). Moreover, EUS-GBD might theoretically have a possible role in patients at high surgical risk with an indication to undergo cholecystectomy or with a high probability of conversion from LC to open cholecystectomy. Properly designed studies are needed to better clarify the role of EUS-GBD in these patient populations.
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Affiliation(s)
- Mihai Rimbaş
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Clinic of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Giulia Tripodi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
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Di Gialleonardo L, Tripodi G, Rizzatti G, Ainora ME, Spada C, Larghi A, Gasbarrini A, Zocco MA. Endoscopic Ultrasound-Guided Locoregional Treatments for Solid Pancreatic Neoplasms. Cancers (Basel) 2023; 15:4718. [PMID: 37835413 PMCID: PMC10571848 DOI: 10.3390/cancers15194718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/23/2023] [Accepted: 09/24/2023] [Indexed: 10/15/2023] Open
Abstract
Solid pancreatic neoplasms are one of the most diagnosed gastrointestinal malignancies thanks to the current and progressive advances in radiologic methods. Endoscopic ultrasound-guided techniques have over time gained a prominent role in the differential diagnosis and characterization of these pancreatic lesions, including pancreatic cancer, neuroendocrine tumors, and metastases. Recently, several endoscopic ultrasound-guided locoregional treatment techniques, which are divided into thermal ablative techniques and non-thermal injection techniques, have been developed and applied in different settings for the treatment of solid pancreatic neoplasms. The most common ablative techniques are radiofrequency, microwave, laser, photodynamic therapy and hybrid techniques such as hybrid cryothermal ablation. The most common injection techniques are ethanol injection, immunotherapy and brachytherapy. In this review, we update evidence about the efficacy and safety of endoscopic ultrasound-guided locoregional treatments for solid pancreatic neoplasms.
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Affiliation(s)
- Luca Di Gialleonardo
- CEMAD Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (L.D.G.); (M.E.A.); (A.G.)
| | - Giulia Tripodi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (G.T.); (G.R.); (C.S.); (A.L.)
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (G.T.); (G.R.); (C.S.); (A.L.)
| | - Maria Elena Ainora
- CEMAD Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (L.D.G.); (M.E.A.); (A.G.)
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (G.T.); (G.R.); (C.S.); (A.L.)
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (G.T.); (G.R.); (C.S.); (A.L.)
| | - Antonio Gasbarrini
- CEMAD Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (L.D.G.); (M.E.A.); (A.G.)
| | - Maria Assunta Zocco
- CEMAD Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (L.D.G.); (M.E.A.); (A.G.)
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Vanella G, Bronswijk M, Arcidiacono PG, Larghi A, Wanrooij RLJV, de Boer YS, Rimbas M, Khashab M, van der Merwe SW. Current landscape of therapeutic EUS: Changing paradigms in gastroenterology practice. Endosc Ultrasound 2023; 12:16-28. [PMID: 36124531 PMCID: PMC10134933 DOI: 10.4103/eus-d-21-00177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Therapeutic EUS has witnessed exponential growth in the last decade, but it has been considered investigational until recently. An increasing body of good-quality evidence is now demonstrating clear advantages over established alternatives, adding therapeutic EUS to management algorithms of complex hepato-pancreato-biliary (HPB) and gastrointestinal (GI) conditions. In this review, the available evidence and clinical role of therapeutic EUS in established and evolving applications will be discussed. A Graphical Summary for each scenario will provide (1) technical steps, (2) anatomical sketch, (3) best-supporting evidence, and (4) role in changing current and future GI practice. Therapeutic EUS has accepted well-established applications such as drainage of symptomatic peripancreatic fluid collections, biliary drainage in failed endoscopic retrograde cholangiopancreatography, and treatment of acute cholecystitis in unfit-for-surgery patients. In addition, good-quality evidence on several emerging indications (e.g., treatment of gastric outlet obstruction, local ablation of pancreatic solid lesions, etc.) is promising. Specific emphasis will be given to how these technical innovations have changed management paradigms and algorithms and expanded the possibilities of gastroenterologists to provide therapeutic solutions to old and emerging clinical needs. Therapeutic EUS is cementing its role in everyday practice, radically changing the treatment of different HPB diseases and other conditions (e.g., GI obstruction). The development of dedicated accessories and increased training opportunities will expand the ability of gastroenterologists to deliver highly effective yet minimally invasive therapies, potentially translating into a better quality of life, especially for oncological and fragile patients.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven; Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS; Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, AGEM Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, AGEM Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mihai Rimbas
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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Vanella G, Tamburrino D, Capurso G, Bronswijk M, Reni M, Dell'Anna G, Crippa S, Van der Merwe S, Falconi M, Arcidiacono PG. Feasibility of therapeutic endoscopic ultrasound in the bridge-to-surgery scenario: The example of pancreatic adenocarcinoma. World J Gastroenterol 2022; 28:976-984. [PMID: 35431499 PMCID: PMC8968520 DOI: 10.3748/wjg.v28.i10.976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/04/2021] [Accepted: 02/15/2022] [Indexed: 02/06/2023] Open
Abstract
Upfront resection is becoming a rarer indication for pancreatic ductal adenocarcinoma, as biologic behavior and natural history of the disease has boosted indications for neoadjuvant treatments. Jaundice, gastric outlet obstruction and acute cholecystitis can frequently complicate this window of opportunity, resulting in potentially deleterious chemotherapy discontinuation, whose resumption relies on effective, prompt and long-lasting management of these complications. Although therapeutic endoscopic ultrasound (t-EUS) can potentially offer some advantages over comparators, its use in potentially resectable patients is primal and has unfairly been restricted for fear of potential technical difficulties during subsequent surgery. This is a narrative review of available evidence regarding EUS-guided choledochoduodenostomy, gastrojejunostomy and gallbladder drainage in the bridge-to-surgery scenario. Proof-of-concept evidence suggests no influence of t-EUS procedures on outcomes of eventual subsequent surgery. Moreover, the very high efficacy-invasiveness ratio over comparators in managing pancreatic cancer-related symptoms or complications can provide a powerful weapon against chemotherapy discontinuation, potentially resulting in higher subsequent resectability. Available evidence is discussed in this short paper, together with technical notes that might be useful for endoscopists and surgeons operating in this scenario. No published evidence supports restricting t-EUS in potential surgical candidates, especially in the setting of pancreatic cancer patients undergoing neoadjuvant chemotherapy. Bridge-to-surgery t-EUS deserves further prospective evaluation.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Gabriele Capurso
- Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven 3000, Belgium
- Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden 2820, Belgium
| | - Michele Reni
- Department of Medical Oncology, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Giuseppe Dell'Anna
- Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven 3000, Belgium
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
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Cucchetti A, Binda C, Dajti E, Sbrancia M, Ercolani G, Fabbri C. Trial sequential analysis of EUS-guided gallbladder drainage versus percutaneous cholecystostomy in patients with acute cholecystitis. Gastrointest Endosc 2022; 95:399-406. [PMID: 34563502 DOI: 10.1016/j.gie.2021.09.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Meta-analytic comparison of EUS-guided gallbladder drainage (EUS-GBD) versus percutaneous gallbladder drainage (PT-GBD) for acute cholecystitis (AC) brings the risk of spurious results if too few studies are included. Trial sequential analysis (TSA) can overcome this, providing information about its credibility. METHODS Comparative studies between EUS-GBD, using lumen-apposing metal stents, and PT-GBD for AC until July 2021 were used for conventional meta-analysis and TSA, which allowed the use of monitoring boundaries and the estimation of the required information size (RIS) needed to prove credibility. RESULTS Four studies accrued 535 patients. Technical success was in favor of PT-GBD (relative risk [RR], .967; P = .036), but TSA estimated that 1663 participants would be needed to avoid a Type I error (false positive). Clinical success was similar (RR, .965; P = .146), and TSA supported the absence of any demonstrable superiority of one therapy rather than a Type II error (false negative). EUS-GBD reduced overall adverse events (RR, .424; P < .001) and unplanned readmissions (RR, .215; P < .001), and TSA confirmed the avoidance of a Type I error, with early RIS achievement, providing necessary credibility. EUS-GBD had fewer reinterventions (RR, .244; P < .001), but a Type I error was not avoided, needing additional 97 patients to the accrued 535 to prove credibility. CONCLUSIONS PT-GBD can provide superior technical success than EUS-GBD if a very large sample size is accrued, thus limiting the single-patient benefit. Clinical success is probably equivalent. EUS-GBD convincingly decreased overall adverse events and unplanned readmissions, whereas the need for reinterventions requires additional studies.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy; Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, Forlì, Italy
| | - Elton Dajti
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, Forlì, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, Forlì, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy; Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, Forlì, Italy
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