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Fugazza A, Andreozzi M, Asadzadeh Aghdaei H, Insausti A, Spadaccini M, Colombo M, Carrara S, Terrin M, De Marco A, Franchellucci G, Khalaf K, Ketabi Moghadam P, Ferrari C, Anderloni A, Capretti G, Nappo G, Zerbi A, Repici A. Management of Malignant Gastric Outlet Obstruction: A Comprehensive Review on the Old, the Classic and the Innovative Approaches. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:638. [PMID: 38674284 PMCID: PMC11052138 DOI: 10.3390/medicina60040638] [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: 02/29/2024] [Revised: 03/31/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
Gastrojejunostomy is the principal method of palliation for unresectable malignant gastric outlet obstructions (GOO). Gastrojejunostomy was traditionally performed as a surgical procedure with an open approach butrecently, notable progress in the development of minimally invasive procedures such as laparoscopic gastrojejunostomies have emerged. Additionally, advancements in endoscopic techniques, including endoscopic stenting (ES) and endoscopic ultrasound-guided gastroenterostomy (EUS-GE), are becoming more prominent. ES involves the placement of self-expandable metal stents (SEMS) to restore luminal patency. ES is commonly the first choice for patients deemed unfit for surgery or at high surgical risk. However, although ES leads to rapid improvement of symptoms, it carries limitations like higher stent dysfunction rates and the need for frequent re-interventions. Recently, EUS-GE has emerged as a potential alternative, combining the minimally invasive nature of the endoscopic approach with the long-lasting effects of a gastrojejunostomy. Having reviewed the advantages and disadvantages of these different techniques, this article aims to provide a comprehensive review regarding the management of unresectable malignant GOO.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Marta Andreozzi
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Hamid Asadzadeh Aghdaei
- Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran P.O. Box 19875-17411, Iran;
| | - Agustin Insausti
- Department of Gastroenterology and Digestive Endoscopy, Medical Association Hospital, IGEA Institute, Patricios 347, Bahia Blanca B8000, Argentina;
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Maria Terrin
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Alessandro De Marco
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Gianluca Franchellucci
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Kareem Khalaf
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada;
| | - Pardis Ketabi Moghadam
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran P.O. Box 19875-17411, Iran;
| | - Chiara Ferrari
- Division of Anaesthesiology, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
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Guilmoteau T, Albouys J, Taibi A, Legros R, Schaefer M, Jacques J. Will Endoscopic-Ultrasound-Guided Choledocoduodenostomy with Electrocautery-Enhanced Lumen-Apposing Metal Stent Placement Replace Endoscopic Retrograde Cholangiopancreatography When Treating Distal Malignant Biliary Obstructions? MEDICINA (KAUNAS, LITHUANIA) 2024; 60:220. [PMID: 38399508 PMCID: PMC10889952 DOI: 10.3390/medicina60020220] [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: 12/10/2023] [Revised: 01/09/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
Malignant distal biliary obstructions are becoming increasingly common, especially in patients with cancers of the pancreatic head, despite progress in medical oncology research. ERCP is the current gold standard for management of such strictures, but the emergence of EC-LAMS has rendered EUS-CDS both safe and efficient. It is a "game changer"; originally intended for ERCP failure, two randomised clinical trials recently proposed EUS-CDS as a first-intent procedure in palliative settings. For resectable diseases, the absence of iatrogenic pancreatitis associated with a lower rate of postsurgical adverse events (compared with ERCP) leads us to believe that EUS-CDS might be used in first-intent as a pre-operative endoscopic biliary drainage.
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Affiliation(s)
- Thomas Guilmoteau
- Hepatogastroenterology, Centre Hospitalier Universitaire Dupuytren, 87000 Limoges, France; (T.G.); (J.A.); (A.T.); (R.L.)
| | - Jérémie Albouys
- Hepatogastroenterology, Centre Hospitalier Universitaire Dupuytren, 87000 Limoges, France; (T.G.); (J.A.); (A.T.); (R.L.)
| | - Abdelkader Taibi
- Hepatogastroenterology, Centre Hospitalier Universitaire Dupuytren, 87000 Limoges, France; (T.G.); (J.A.); (A.T.); (R.L.)
| | - Romain Legros
- Hepatogastroenterology, Centre Hospitalier Universitaire Dupuytren, 87000 Limoges, France; (T.G.); (J.A.); (A.T.); (R.L.)
| | - Marion Schaefer
- Hepatogastroenterology, Nancy Regional University Hospital Center, 54500 Nancy, France;
| | - Jérémie Jacques
- Hepatogastroenterology, Centre Hospitalier Universitaire Dupuytren, 87000 Limoges, France; (T.G.); (J.A.); (A.T.); (R.L.)
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Giri S, Mohan BP, Jearth V, Kale A, Angadi S, Afzalpurkar S, Harindranath S, Sundaram S. Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis. Gastrointest Endosc 2023; 98:515-523.e18. [PMID: 37392952 DOI: 10.1016/j.gie.2023.06.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/01/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND AND AIMS Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD. METHODS A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model. RESULTS One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%). CONCLUSIONS Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
| | - Vaneet Jearth
- Department of Gastroenterology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sumaswi Angadi
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Shivaraj Afzalpurkar
- Department of Gastroenterology, Nanjappa Multispecialty Hospital, Davanagere, India
| | - Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Bronswijk M, Vanella G, van Wanrooij RLJ, Samanta J, Lauwereys J, Pérez-Cuadrado-Robles E, Dell'Anna G, Dhar J, Gupta V, van Malenstein H, Laleman W, Jaekers J, Topal H, Topal B, Crippa S, Falconi M, Besselink MG, Messaoudi N, Arcidiacono PG, Kunda R, Van der Merwe S. Same-session double EUS-guided bypass versus surgical gastroenterostomy and hepaticojejunostomy: an international multicenter comparison. Gastrointest Endosc 2023; 98:225-236.e1. [PMID: 36990124 DOI: 10.1016/j.gie.2023.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/16/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND AND AIMS Gastric outlet and biliary obstruction are common manifestations of GI malignancies and some benign diseases for which standard treatment would be surgical gastroenterostomy and hepaticojejunostomy (ie, "double bypass"). Therapeutic EUS has allowed for the creation of an EUS-guided double bypass. However, same-session double EUS-guided bypass has only been described in small proof-of-concept series and lacks a comparison with surgical double bypass. METHODS A retrospective multicenter analysis was performed of all consecutive same-session double EUS-guided bypass procedures performed in 5 academic centers. Surgical comparators were extracted from these centers' databases from the same time interval. Efficacy, safety, hospital stay, nutrition and chemotherapy resumption, long-term patency, and survival were compared. RESULTS Of 154 identified patients, 53 (34.4%) received treatment with EUS and 101 (65.6%) with surgery. At baseline, patients undergoing EUS exhibited higher American Society of Anesthesiologists scores and a higher median Charlson Comorbidity Index (9.0 [interquartile range {IQR}, 7.0-10.0] vs 7.0 [IQR, 5.0-9.0], P < .001). Technical success (96.2% vs 100%, P = .117) and clinical success rates (90.6% vs 82.2%, P = .234) were similar when comparing EUS and surgery. Overall (11.3% vs 34.7%, P = .002) and severe adverse events (3.8% vs 19.8%, P = .007) occurred more frequently in the surgical group. In the EUS group, median time to oral intake (0 days [IQR, 0-1] vs 6 days [IQR, 3-7], P < .001) and hospital stay (4.0 days [IQR, 3-9] vs 13 days [IQR, 9-22], P < .001) were significantly shorter. CONCLUSIONS Despite being used in a patient population with more comorbidities, same-session double EUS-guided bypass achieved similar technical and clinical success and was associated with fewer overall and severe adverse events when compared with surgical gastroenterostomy and hepaticojejunostomy.
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Affiliation(s)
- Michiel Bronswijk
- Department of Gastroenterology and Hepatology; Department of Gastroenterology and Hepatology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | | | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Jayanta Samanta
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Jonas Lauwereys
- Department of Gastroenterology and Hepatology; Department of Gastroenterology and Hepatology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, APHP, Centre, University of Paris Cité, Paris, France
| | | | - Jahnvi Dhar
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Vikas Gupta
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | | | - Wim Laleman
- Department of Gastroenterology and Hepatology
| | - Joris Jaekers
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Halit Topal
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Baki Topal
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Nouredin Messaoudi
- Department of Surgery, Department of Gastroenterology and Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Rizzo GEM, Carrozza L, Quintini D, Ligresti D, Traina M, Tarantino I. A Systematic Review of Endoscopic Treatments for Concomitant Malignant Biliary Obstruction and Malignant Gastric Outlet Obstruction and the Outstanding Role of Endoscopic Ultrasound-Guided Therapies. Cancers (Basel) 2023; 15:cancers15092585. [PMID: 37174051 PMCID: PMC10177271 DOI: 10.3390/cancers15092585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/22/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The treatments for cancer palliation in patients with concomitant malignant biliary obstruction (MBO) and gastric outlet obstruction (MGOO) are still under investigation due to the lack of evidence available in the medical literature. We performed a systematic search and critical review to investigate efficacy and safety among patients with MBO and MGOO undergoing both endoscopic ultrasound-guided biliary drainage (EUS-BD) and MGOO endoscopic treatment. METHODS A systematic literature search was performed in PubMed, MEDLINE, EMBASE, and the Cochrane Library. EUS-BD included both transduodenal and transgastric techniques. Treatment of MGOO included duodenal stenting or EUS-GEA (gastroenteroanastomosis). Outcomes of interest were technical success, clinical success, and rate of adverse events (AEs) in patients undergoing double treatment in the same session or within one week. RESULTS 11 studies were included in the systematic review for a total number of 337 patients, 150 of whom had concurrent MBO and MGOO treatment, fulfilling the time criteria. MGOO was treated by duodenal stenting (self-expandable metal stents) in 10 studies, and in one study by EUS-GEA. EUS-BD had a mean technical success of 96.4% (CI 95%, 92.18-98.99) and a mean clinical success of 84.96% (CI 95%, 67.99-96.26). The average frequency of AEs for EUS-BD was 28.73% (CI 95%, 9.12-48.33). Clinical success for duodenal stenting was 90% vs. 100% for EUS-GEA. CONCLUSIONS EUS-BD could become the preferred drainage in the case of double endoscopic treatment of concomitant MBO and MGOO in the near future, with the promising EUS-GEA becoming a valid option for MGOO treatment in these patients.
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Affiliation(s)
- Giacomo Emanuele Maria Rizzo
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy
- Ph.D. Program, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Lucio Carrozza
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy
| | - Dario Quintini
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy
| | - Dario Ligresti
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy
| | - Mario Traina
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy
- Ilaria Tarantino, Chief of Endoscopy Ultrasound Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy
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Vanella G, Bronswijk M, van Wanrooij RLJ, Dell'Anna G, Laleman W, van Malenstein H, Voermans RP, Fockens P, Van der Merwe S, Arcidiacono PG. Combined endoscopic mAnagement of BiliaRy and gastrIc OutLET obstruction (CABRIOLET Study): A multicenter retrospective analysis. DEN OPEN 2023; 3:e132. [PMID: 35898844 PMCID: PMC9307724 DOI: 10.1002/deo2.132] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/02/2022] [Accepted: 05/15/2022] [Indexed: 11/11/2022]
Abstract
Objectives Combined biliary obstruction and gastric outlet obstruction (GOO) represent a challenging clinical scenario despite developments in therapeutic endoscopic ultrasonography (EUS) as GOO might impair EUS‐guided biliary drainage. Little is known about the effectiveness of different therapeutic combinations used to treat double obstruction, especially regarding stent patency. Methods All consecutive patients with double obstruction treated between 2016 and 2021 in three tertiary academic centres were eligible for inclusion. Five combinations involving enteral stenting (ES), EUS‐guided gastroenterostomy (EUS‐GE), hepaticogastrostomy (EUS‐HGS), choledochoduodenostomy (EUS‐CDS), and transpapillary biliary stenting (TPS) were evaluated for dysfunction during follow‐up, either as proportions or dysfunction‐free survival (DFS) using Kaplan–Meier estimates. Results Ninety‐three patients were included (male 46%; age 67 [interquartile range 60–76] years; pancreatic cancer 73%, metastatic 57%), resulting in 103 procedure combinations. Different combinations showed significantly different overall dysfunction rates (p = 0.009), ranging from the null rate of EUS‐GE+HG to the 18% rate of EUS‐GE+TPS, 31% of EUS‐GE+EUS‐CD, 53% of ES+TPS and 83% of ES+EUS‐CDS. Sub‐analyses restricted to biliary dysfunction confirmed these trends. A multivariate Cox proportional‐hazards regression of DFS, a stenosis distal to the papilla (HR 3.2 [1.5–6.9]) and ES+EUS‐CDS (HR 5.6 [2–15.7]) independently predicted dysfunction. Conclusions Despite a lack of statistical power per combination, this study introduces new associations beyond the increased risk of GOO recurrence with ES versus EUS‐GE. EUS‐CDS showed reduced effectiveness and frequent dysfunction in the context of GOO, especially when combined with ES. EUS‐GE+HGS or EUS‐GE+TPS in this setting might result in superior patency. These results suggest that a prospective evaluation of the optimal endoscopic approach to malignant double obstruction is needed.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre IRCCS San Raffaele Scientific Institute and University Milan Italy
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium
- Department of Gastroenterology and Hepatology Imelda General Hospital Bonheiden Belgium
| | - Roy LJ van Wanrooij
- Department of Gastroenterology and Hepatology Amsterdam UMC, Vrije Universiteit, Amsterdam Gastroenterology Endocrinology and Metabolism Amsterdam the Netherlands
| | - Giuseppe Dell'Anna
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre IRCCS San Raffaele Scientific Institute and University Milan Italy
| | - Wim Laleman
- Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium
| | - Hannah van Malenstein
- Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism Amsterdam the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology Amsterdam UMC, Vrije Universiteit, Amsterdam Gastroenterology Endocrinology and Metabolism Amsterdam the Netherlands
- Department of Gastroenterology and Hepatology Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism Amsterdam the Netherlands
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre IRCCS San Raffaele Scientific Institute and University Milan Italy
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7
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Hu J, Wang G, Gao H, Sheng S, Sun S. The formation process and mechanism of gastrointestinal anastomosis after retrieval anchor-assisted endoscopic ultrasound-guided gastroenterostomy: a preclinical study. Surg Endosc 2023; 37:2043-2049. [PMID: 36289084 DOI: 10.1007/s00464-022-09565-4] [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: 11/21/2021] [Accepted: 08/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a promising method of treating gastric outlet obstruction. However, no study has investigated gastrointestinal anastomosis formation after EUS-GE. We aimed to evaluate the formation of gastrointestinal anastomosis after EUS-GE in a porcine model. METHODS Retrieval anchor-assisted EUS-GE was performed on 15 Bama mini pigs. Five pigs each were randomly euthanized 3, 7, and 14 days postoperatively to evaluate the formation of gastrointestinal anastomosis and measure the anastomotic distance. The expression of transforming growth factor-β1(TGF-β1) and Smad3 in the anastomosis site were examined by immunohistochemistry. RESULTS EUS-GE was successfully performed in all 15 pigs. The mean procedure time was 29.2 ± 6.0 (range 18-40) minutes. The anastomotic distance was 34.0 ± 3.6 cm in 14 pigs. The site of gastroenterostomy of one pig was at the ileum. For pigs euthanized 3 days postoperatively, the structure was mechanically maintained by a stent. For pigs euthanized 7 or 14 days postoperatively, the stomach and small intestine were anastomosed to form a stable structure. The level of TGF-β1 and Smad3 in the anastomosis site gradually increased from 3 to 14 days after EUS-GE. TGF-β1 and Smad3 expression had a significant difference between 3 days, 7 days, and 14 days after EUS-GE (P < 0.05). CONCLUSIONS For EUS-GE, the stomach and small intestine were initially linked together mechanically and spontaneously anastomosed to form a stable structure 7 days postoperatively. TGF-β1 and Smad3 play an important role in the formation of a stable structure of gastrointestinal anastomosis.
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Affiliation(s)
- Jinlong Hu
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Guoxin Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Haixin Gao
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Shiyun Sheng
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China.
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Canakis A, Hathorn KE, Irani SS, Baron TH. Single session endoscopic ultrasound-guided double bypass (hepaticogastrostomy and gastrojejunostomy) for concomitant duodenal and biliary obstruction: A case series. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:941-949. [PMID: 34619022 DOI: 10.1002/jhbp.1055] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/15/2021] [Accepted: 09/13/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Concomitant malignant biliary and gastric outlet obstruction can be difficult to manage endoscopically with traditional endoscopic retrograde cholangiopancreatography (ERCP) and luminal stenting. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HG) and gastrojejunostomy (GJ) are novel techniques that can relieve both obstructions in a single session. This study aims to describe the outcomes of combined, single session EUS-HG and EUS-GJ. METHODS This is a two-center retrospective study of consecutive patients who underwent same session EUS-HG and EUS-GJ. The primary outcome was technical success. Secondary outcomes included adverse events (AE), reduction in total serum bilirubin, length of hospital stay (LOS), and re-intervention rates. RESULTS A total of 23 patients underwent EUS-HG and EUS-GJ (12 males, mean age 66.4 years). Twenty-one were performed for malignant obstruction. Technical success was 100% and 95.6% for HG and GJ, respectively. All patients subsequently tolerated a soft diet and 72.7% (16/22) of patients had a 50% reduction in bilirubin post-procedure. The median LOS for the 17 patients who were not discharged home immediately following the procedure was 2 (range 1-20) days. There were five AEs (2 mild, 3 moderate). Only three patients required reintervention (interventional radiology-guided biliary drainage, stent exchange for a benign biliary stricture, and placement of a second stent through an occluded distal common bile duct stent) over a median follow-up of 78 days. One patient with pancreatic cancer underwent successful tumor resection. CONCLUSION Single session EUS-guided double bypass (HG and GJ) is technically feasible and safe when conducted by experienced endosonographers. Larger, comparative studies are needed.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kelly E Hathorn
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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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: 0.7] [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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