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Rimbaş M, Anderloni A, Napoléon B, Seicean A, Forti E, Crinò SF, Tarantino I, Arcidiacono PG, Fabbri C, Rizzatti G, Amato A, Voiosu T, Fugazza A, Moșteanu O, Ginès À, de Nucci G, Fusaroli P, Nguyen NQ, Di Mitri R, Minelli Grazioli L, Mutignani M, Archibugi L, Binda C, Cominardi A, Barbera C, Fernández-Esparrach G, Palazzo L, Palazzo M, Poley JW, Spada C, Valerii G, Itoi T, Matsunami Y, Mateescu RB, Băicuș C, Costamagna G, Larghi A. Common bile duct size in malignant distal obstruction and lumen-apposing metal stents: a multicenter prospective study. Endosc Int Open 2021; 9:E1801-E1810. [PMID: 34790548 PMCID: PMC8589552 DOI: 10.1055/a-1526-1208] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/26/2021] [Indexed: 11/11/2022] Open
Abstract
Background and study aims Feasibility of EUS-guided choledochoduodenostomy (EUS-CDS) using available lumen-apposing stents (LAMS) is limited by the size of the common bile duct (CBD) (≤ 12 mm, cut-off for experts; 15 mm, cut-off for non-experts). We aimed to assess the prevalence and predictive factors associated with CBD size ≥ 12 and 15 mm in naïve patients with malignant distal biliary obstruction (MDBO). Patients and methods This was a prospective cohort study involving 22 centers with assessment of CBD diameter and subjective feasibility of the EUS-CDS performance in naïve jaundiced patients undergoing EUS evaluation for MDBO. Results A total of 491 patients (mean age 69 ± 12 years) with mean serum bilirubin of 12.7 ± 6.6 mg/dL entered the final analysis. Dilation of the CBD ≥ 12 and 15 mm was detected in 78.8 % and 51.9 % of cases, respectively. Subjective feasibility of EUS-CDS was expressed by endosonographers in 91.2 % for a CBD ≥ 12 mm and in 96.5 % for a CBD ≥ 15 mm. On multivariate analysis, age ( P < 0.01) and bilirubin level ( P ≤ 0.001) were the only factors associated with both CBD dilation ≥ 12 and ≥ 15 mm. These variables were poorly associated with the extent of duct dilation; however, based on them a prediction model could be constructed that satisfactorily predicted CBD size ≥ 12 mm in patients at least 70 years and a bilirubin level ≥ 7 mg/dL. Conclusions Our study showed that at presentation in a large cohort of patients with MDBO, EUS-CDS can be potentially performed in three quarters to half of cases by expert and less experienced endosonographers, respectively. Dedicated stents or devices with different designs able to overcome the limitations of existing electrocautery-enhanced LAMS for EUS-CDS are needed.
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Affiliation(s)
- Mihai Rimbaş
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Bertrand Napoléon
- Endoscopy Unit, Jean Mermoz Private Hospital, Ramsay Generale de Santé, Lyon, France
| | - Andrada Seicean
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology, Iuliu Haţieganu University of Medicine, Cluj-Napoca, Romania
| | - Edoardo Forti
- Digestive Endoscopy Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione, Palermo, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Arnaldo Amato
- Gastroenterology Division, Valduce Hospital, Como, Italy
| | - Theodor Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania,Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Ofelia Moșteanu
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology, Iuliu Haţieganu University of Medicine, Cluj-Napoca, Romania
| | - Àngels Ginès
- Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | - Germana de Nucci
- Gastroenterology Unit, ASST Rhodense, Garbagnate Milanese, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Nam Quoc Nguyen
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, Australia
| | - Roberto Di Mitri
- Gastroenterology and Endoscopy Unit, ARNAS Civico – Di Cristina – Benfratelli, Palermo, Italy
| | | | | | - Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Italy
| | - Anna Cominardi
- Gastroenterology Unit, Hospital of Imola, Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Carmelo Barbera
- U.O.C. di Gastroenterologia ed Endoscopia Digestiva, Ospedale Giuseppe Mazzini, ASL Teramo, Italy
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | | | - Maxime Palazzo
- Digestive Endoscopy Unit, Beaujon University Hospital, Clichy-la-Garenne, France
| | - Jan Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italia
| | - Giorgio Valerii
- U.O.C. di Gastroenterologia ed Endoscopia Digestiva, Ospedale Giuseppe Mazzini, ASL Teramo, Italy
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Radu Bogdan Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania,Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Cristian Băicuș
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
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Baimas-George M, Passeri MJ, Lyman WB, Dries A, Narang T, Deal S, Lewis J, Chauhan S, Martinie J, Vrochides D, Baker E, Iannitti D. A Single-Center Experience with Minimally Invasive Transgastric ERCP in Patients with Previous Gastric Bypass: Lessons Learned and Technical Considerations. Am Surg 2020. [DOI: 10.1177/000313482008600425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
As bariatric surgery increases, there is a growing population of patients with biliary obstruction and anatomy which precludes transoral access through endoscopic retrograde cholangiopancreatography (ERCP). Minimally invasive transgastric ERCP (TG-ERCP) offers a feasible alternative for the treatment. A retrospective review was performed of all patients who underwent laparoscopic or robotic-assisted TG-ERCP between 2010 and 2017. Chart abstraction collected demographics, procedural details, success rate, and postoperative outcomes. Forty patients were identified, of which 38 cases were performed laparoscopically and two robotically. Median operative time was 163 minutes, with an estimated blood loss of 50 cc. TG-ERCP was performed successfully in 36 cases (90%); sphincterotomy was completed in 35 patients (97%). Sixty per cent already had a cholecystectomy; in the remaining patients, it was performed concurrently. Major complications included stomach perforation (n = 1), pancreatitis (n = 3), and anemia requiring transfusion (n = 2). In patients with biliary obstruction and anatomy not suitable for ERCP, TG-ERCP can be performed in a minimally invasive fashion, with a high rate of technical success and low morbidity. We describe a stepwise, reproducible technique because it is an essential tool for the shared armamentarium of endoscopists and surgeons.
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Affiliation(s)
- Maria Baimas-George
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael J. Passeri
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - William B. Lyman
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Andrew Dries
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Tarun Narang
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen Deal
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jason Lewis
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Shailendra Chauhan
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John Martinie
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin Baker
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David Iannitti
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Pizzicannella M, Caillol F, Pesenti C, Bories E, Ratone JP, Giovannini M. EUS-guided biliary drainage for the management of benign biliary strictures in patients with altered anatomy: A single-center experience. Endosc Ultrasound 2020; 9:45-52. [PMID: 31552913 PMCID: PMC7038727 DOI: 10.4103/eus.eus_55_19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Objectives: The management of benign biliary stricture in patients with altered anatomy secondary to surgery is challenging. Percutaneous transhepatic biliary drainage (BD) represents the standard therapy for benign biliary stricture, but it is associated with nontrivial morbidity rates. Despite the increasing application of guided BD (EUS-BD) for the management of malignant obstruction, its role in patients with benign biliary stricture is limited. This retrospective study aimed to evaluate the feasibility, safety, and clinical effectiveness of EUS-BD with multiple transanastomotic plastic stent treatment in patients with benign biliary stricture. Materials and Methods: This study included consecutive patients who underwent EUS-BD for benign biliary stenosis at our center. EUS-BD with fully covered self-expandable metal stent placement was performed first. When feasible, the stricture was treated by balloon dilation with the placement of a transanastomotic double-pigtail plastic stent. Scheduled procedures were repeated to remove the metal stent and replace the plastic stent to treat the stenosis. Technical success and adverse events (AEs) were assessed. Results: Twelve patients underwent EUS-BD for benign biliary strictures. Procedural and clinical successes were achieved in all patients (100%). Multistenting treatment was performed in 10/12 patients (77%). The median number of stents inserted, maximum number of stents placed, and median time of retreatment were 2.4 (range: 1–4), 4, and 3.4 (range: 1–7), respectively. In total, 4/12 patients (33.3%) developed AEs that required endoscopic interventions (Clavien-Dindo Grade III). Conclusions: EUS-BD with the placement of multiple trans-stenosis plastic stents is a safe, feasible, and well-tolerated alternative for the management of benign biliary stricture in patients with surgery-altered anatomy. Long-term follow-up is necessary to support our results.
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Affiliation(s)
| | - Fabrice Caillol
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Erwan Bories
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Marc Giovannini
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
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8
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Zhang HC, Tamil M, Kukreja K, Singhal S. Review of Simultaneous Double Stenting Using Endoscopic Ultrasound-Guided Biliary Drainage Techniques in Combined Gastric Outlet and Biliary Obstructions. Clin Endosc 2019; 53:167-175. [PMID: 31405265 PMCID: PMC7137573 DOI: 10.5946/ce.2019.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/24/2019] [Indexed: 12/16/2022] Open
Abstract
Concomitant malignant gastric outlet obstruction and biliary obstruction may occur in patients with advanced cancers affecting these anatomical regions. This scenario presents a unique challenge to the endoscopist in selecting an optimal management approach. We sought to determine the efficacy and safety of endoscopic techniques for treating simultaneous gastric outlet and biliary obstruction (GOBO) with endoscopic ultrasound (EUS) guidance for biliary drainage. An extensive literature search for peer-reviewed published cases yielded 6 unique case series that either focused on or included the use of EUS-guided biliary drainage (EUS-BD) with simultaneous gastroduodenal stenting. In our composite analysis, a total of 51 patients underwent simultaneous biliary drainage through EUS, with an overall reported technical success rate of 100% for both duodenal stenting and biliary drainage. EUS-guided choledochoduodenostomy or EUS-guided hepaticogastrostomy was employed as the initial technique. In 34 cases in which clinical success was ascribed, 100% derived clinical benefit. The common adverse effects of double stenting included cholangitis, stent migration, bleeding, food impaction, and pancreatitis. We conclude that simultaneous double stenting with EUS-BD and gastroduodenal stenting for GOBO is associated with high success rates. It is a feasible and practical alternative to percutaneous biliary drainage or surgery for palliation in patients with associated advanced malignancies.
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Affiliation(s)
- Hao Chi Zhang
- Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, TX, USA.,Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Monica Tamil
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Keshav Kukreja
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
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