Effectiveness of endoscopic ultrasound (EUS)-guided choledochoduodenostomy vs. EUS-guided gallbladder drainage for jaundice in patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography: Retrospective, multicenter study (GALLBLADEUS Study)

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis

With technological advances in endoscopic ultrasonography, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was introduced as a treatment option for acute cholecystitis. Recently, new studies have emerged, suggesting that EUS-GBD has a lower adverse event rate and reintervention rate, when compared to percutaneous drainage and endoscopic transpapillary gallbladder drainage. There is growing interest in the different technical aspects of EUS-GBD, such as the puncture approach, choice of stents, and long-term management. There are also cohorts on performing EUS-GBD in potential surgical candidates. This review article gathers the latest evidence on EUS-GBD, including its indications, procedural techniques, choice of equipment, outcomes, postprocedural care, and the controversial extended indications.

Endoscopic Ultrasound-Guided Treatments for Pancreatic Cancer: Understanding How Endoscopic Ultrasound Has Revolutionized Management of Pancreatic Cancer

Pancreatic cancer is associated with high rates of morbidity and mortality. Endoscopic ultrasound (EUS)-guided biopsy has become the standard diagnostic modality per the guidelines. The use of EUS has been growing for providing various treatments in patients with pancreatic cancers: biliary and gallbladder drainage for those with malignant biliary obstruction, gastroenterostomy for malignant gastric outlet obstruction, celiac plexus/ganglia neurolysis for pain control, radiofrequency ablation, placement of fiducial markers, and injection of local chemotherapeutic agents. In this review, we explore the recent clinical studies evaluating the EUS-guided treatments in pancreatic cancer.

The Role of Therapeutic Endoscopic Ultrasound in Management of Malignant Double Obstruction (Biliary and Gastric Outlet): A Comprehensive Review with Clinical Scenarios

Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic biliary drainage for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography failure

In a recent issue of the World Journal of Gastrointestinal Surgery, a meta-analysis investigated the safety and efficacy of electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) implantation for managing malignant biliary obstruction following failed endoscopic retrograde cholangiopancreatography. This manuscript endeavors to offer a comprehensive look at the progression of endoscopic ultrasound-guided biliary drainage (EUS-BD) technologies, weighing their merits and drawbacks against traditional percutaneous methods. Several meta-analyses and randomized controlled trials have compared the performance of EUS-BD and percutaneous transhepatic cholangiodrainage (PTCD). These studies revealed that the technical success rate, clinical success rate, and adverse events were similar between EUS-BD and PTCD. Nevertheless, given that most of these studies predate 2015, the safety and effectiveness of novel EUS-BD techniques, including ECE-LAMS, compared with those of percutaneous biliary drainage remain elusive. Further investigation is imperative to ascertain whether these novel EUS-BD techniques can safely and efficaciously replace conventional percutaneous therapeutic approaches.

Role of endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction

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.

Endoscopic Ultrasound-guided Transmural Biliary Drainage With 6 mm and 8 mm Cautery-enhanced Lumen-apposing Metal Stents: A Multicenter Collaborative Study

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP) may be unsuccessful in patients with duodenal stenosis or malignant ampullary infiltration. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been proposed as an alternative. We aimed to assess the efficacy and safety of EUS-BD for malignant distal bile duct obstruction using the newly introduced smaller caliber 6 or 8 mm cautery-enhanced lumen-apposing metal stent.

METHODS

A multicenter retrospective study was performed on patients with unresectable malignant distal bile duct obstruction who underwent EUS-BD between 2021 and 2022 after unsuccessful ERCP.

RESULTS

Thirty-two patients were included [7 (53.13%) males], with a mean age of 72.2 ± 12.5 years. The technical success rate was 100%. Altered anatomy was present in 2 (6.25%). The indication for drainage was biliary obstruction from pancreatic cancer in 26 patients (84.5%), cholangiocarcinoma in 3 (9.4%), and ampullary mass in 3 (9.4%). The procedure was performed mostly in an outpatient setting (n = 19, 59.38%). The clinical success rate was 92.3% [bilirubin: 14.1 (SD: 8.9) preprocedure vs 4.9 (SD: 1.1) postprocedure; P = 0.0001]. There was one early adverse event of a perforation, which was closed endoscopically and drained percutaneously. Delayed adverse events included food impaction of the stent (n = 1), which was resolved with a repeat procedure and insertion of a double pigtail stent.

CONCLUSION

This study demonstrates the feasibility of EUS-BD drainage using smaller caliber 6 or 8 mm lumen-apposing metal stent to relieve malignant distal bile duct obstruction in patients who fail conventional ERCP.

Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives

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.