Endoscopic ultrasound‐guided gallbladder drainage as a first approach for jaundice palliation in unresectable malignant distal biliary obstruction: Prospective study

Abstract

ObjectivesEndoscopic retrograde cholangiopancreatography (ERCP) represents the gold standard for jaundice palliation in patients with distal malignant biliary obstruction (DMBO). Biliary drainage using electrocautery lumen apposing metal stent (EC‐LAMS) is currently a well‐established procedure when ERCP fails. In a palliative setting the endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) could represent an easy and valid option. We performed a prospective study with a new EC‐LAMS with the primary aim to assess the clinical success rate of EUS‐GBD as a first‐line approach to the palliation of DMBO.MethodsIn all, 37 consecutive patients undergoing EUS‐GBD with a new EC‐LAMS were prospectively enrolled. Clinical success was defined as bilirubin level decrease >15% within 24 h and >50% within 14 days after EC‐LAMS placement.ResultsThe mean age was 73.5 ± 10.8 years; there were 17 male patients (45.9%). EC‐LAMS placement was technically feasible in all patients (100%) and the clinical success rate was 100%. Four patients (10.8%) experienced adverse events, one bleeding, one food impaction, and two cystic duct obstructions because of disease progression. No stent‐related deaths were observed. The mean hospitalization was 7.7 ± 3.4 days. Median overall survival was 4 months (95% confidence interval 1–8).ConclusionEndoscopic ultrasound‐guided gallbladder drainage with the new EC‐LAMS is a valid option in palliative endoscopic biliary drainage as a first‐step approach in low survival patients with malignant jaundice unfit for surgery. A smaller diameter EC‐LAMS should be preferred, particularly if the drainage is performed through the stomach, to avoid potential food impaction, which could result in stent dysfunction.

Therapeutic Endoscopic Ultrasound for Complications of Pancreatic Cancer

“…The development of the LAMS in particular has greatly facilitated performing EUS-CD and EUS-GE, thus enabling one-step stent placement, which can reduce procedure time and decrease the rate of adverse events. While the majority of studies on LAMS have utilized one particular device (Hot AXIOS, Boston Scientific, Marlborough, MA, USA), it should be noted that other LAMS devices have also been examined (Hot Spaxus, Taewoong Medical, Kimpo, Republic of Korea) for these indications [ 69 , 70 ]. While data reporting regarding these procedures and their adverse events remains an ongoing process, one must remember that all the reported studies involve expert centers with highly experienced endoscopists and for the time being, we recommend referral to tertiary centers with a high comfort level for these procedures.…”

Endoscopy Ultrasound-Guided Biliary Drainage Using Lumen Apposing Metal Stent in Malignant Biliary Obstruction

“…The authors reported a technical success rate of 100 % and a clinical success rate of 81.3 %, with a mean total bilirubin reduction after two weeks of 66.5 % and an AEs rate of 10.4 % [53]. Moreover, EUS-GBD was considered a valid first-line option for BD for low-survival patients with unresectable DMBO, as shown in 37 patients with 100% technical and clinical success rates and an AEs rate of 10.8% [54]. Possible complications of EUS-GBD include bleeding, cholangitis/cholecystitis, bile leak, sepsis, peritonitis, stent migration and perforation.…”

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

“…EUS-GBD has also been investigated as a primary drainage technique in distal MBO. A prospective study including 37 consecutive patients reported 100% technical and clinical success, with 10.8% adverse events, including three stent disfunctions secondary to food impaction (n = 1) and cystic duct obstruction due to neoplastic progression (n = 2) [81]. Beyond the understandable enthusiasm with such good results, it should be recognized that long-term clinical data are still scarce, and we still do not know how reliable this route of drainage will be over time, especially in patients with a cystic duct that takes off very close to the neoplastic mass [82,83].…”