Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

Abstract

Main Recommendations 1 ESGE recommends a prolonged course of a prophylactic broad-spectrum antibiotic in patients with ascites who are undergoing therapeutic endoscopic ultrasound (EUS) procedures.Strong recommendation, low quality evidence. 2 ESGE recommends placement of partially or fully covered self-expandable metal stents during EUS-guided hepaticogastrostomy for biliary drainage in malignant disease.Strong recommendation, moderate quality evidence. 3 ESGE recommends EUS-guided pancreatic duct (PD) drainage should only be performed in high volume expert centers, owing to the complexity of this technique and the high risk of adverse events.Strong recommendation, low quality evidence. 4 ESGE recommends a stepwise approach to EUS-guided PD drainage in patients with favorable anatomy, starting with rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP), followed by antegrade or transmural drainage only when RV-ERP fails or is not feasible.Strong recommendation, low quality evidence. 5 ESGE suggests performing transduodenal EUS-guided gallbladder drainage with a lumen-apposing metal stent (LAMS), rather than using the transgastric route, as this may reduce the risk of stent dysfunction.Weak recommendation, low quality evidence. 6 ESGE recommends using saline instillation for small-bowel distension during EUS-guided gastroenterostomy.Strong recommendation, low quality evidence. 7 ESGE recommends the use of saline instillation with a 19G needle and an electrocautery-enhanced LAMS for EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) procedures.Strong recommendation, low quality evidence. 8 ESGE recommends the use of either 15- or 20-mm LAMSs for EDGE, with a preference for 20-mm LAMSs when considering a same-session ERCP.Strong recommendation, low quality evidence.

Endoscopic ultrasound-guided biliary drainage in malignant distal biliary obstruction

“…Then, EUS-HGS or PTBD can be performed as a salvage method. 8 However, reflux of duodenal contents such as food material can lead to stent dysfunction due to sludge formation or ascending infection. 9 Recently, the method of placing EUS-guided antegrade covered metal stent with long duodenal extension was introduced to prevent reflux cholangitis and tumor in-growth.…”

“…15 It may be difficult to seal the anastomosis adequately with a plastic stent or uncovered self-expandable metal stent (SEMS), increasing the risk of bile leakage. 8 Thus, either fully covered SEMS (FCSEMS) or LAMS is preferred for EUS-CDS. Small caliber LAMSs are appropriate for an EUS-CDS procedure because the procedure usually causes the reduction of common bile duct (CBD) diameter and the use of larger caliber LAMSs may damage the CBD.…”

“…Small caliber LAMSs are appropriate for an EUS-CDS procedure because the procedure usually causes the reduction of common bile duct (CBD) diameter and the use of larger caliber LAMSs may damage the CBD. 8 Electrocautery-enhanced LAMSs have improved the performance of direct EUS-CDS by removing the need for accessory exchanges and reducing the risk of procedural failure. In the electrocautery-enhanced LAMSs, an electrocautery wire was added to the distal tip of the delivery catheter to apply cutting current that allows the passage of the device through the gastrointestinal and the bile duct walls, without the need for prior dilation.…”

“…17 When performing EUS-CDS using an electrocautery-enhanced LAMS, the use of free-hand technique is recommended. 8 It allows direct access to the CBD without a guidewire. However, EUS-CDS with LAMS may be difficult for CBDs with small diameter because deployment of the distal flange of the stent may be difficult.…”

Radiation exposure during modern therapeutic endoscopic ultrasound procedures and standard alternatives

“…Fluid collection drainage (EUS-FCD) with lumen apposing metal stents (LAMS, N = 26) were performed fluoroless, while EUS-FCD with double-pigtail plastic stents (DPPS, N = 28) required higher RE (KAP = 23 ). EUS-guided gallbladder drainage (EUS-GBD, N = 6) required scarce RE (KAP = 9 [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]) for coaxial DPPS placement. EUS-GE (N = 27) required higher RE than duodenal stenting (KAP = 44 versus 29 , P = 0.03).…”