Treatment Of Distal Biliary Obstruction Research Articles

S83 Fully Covered vs Uncovered Self-Expanding Metal Stents for the Treatment of Distal Malignant Biliary Obstruction in the Setting of Locally Advanced Pancreatic Cancer

Introduction: Self-expanding metal stents (SEMS) are preferred for the treatment of distal biliary obstruction (dMBO) caused by pancreatic cancer. Optimizing biliary drainage in the neoadjuvant period while patients await definitive surgical treatment is essential. The aim of this study is to compare clinical outcomes of patients who underwent fully covered (FCSEMS) versus uncovered (UCSEMS) placement for the treatment of dMBO due to locally advanced pancreatic cancer (LAPC). Methods: Consecutive patients who underwent biliary SEMS placement for treatment of dMBO in the setting of LAPC were identified from a single, tertiary care center between May 2017 and May 2021. Patients were categorized into FCSEMS or UCSEMS cohorts based on the type of stent placed during index ERCP. UCSEMS included WallFlex (Boston Scientific,Boston,MA) and Flexxus (ConMed,Utica,NY). Primary outcomes were clinical success, overall incidence of adverse events (AEs), and need for unplanned endoscopic reintervention. Secondary outcomes included stent patency, type of AEs, and overall survival. Results: 817 cases of ERCP with SEMS placement were reviewed to identify 187 patients with dMBO due to LAPC. 35 (18.7%) patients underwent FCSEMS placement and 152 (81.3%) UCSEMS (49 WallFlex, 103 Flexxus). High rates of clinical success were seen in both cohorts (92.1% UCSEMS vs. 97.1% FCSEMS, p = 0.29). (Table) Stent patency was significantly longer in patients who underwent FCSEMS placement (Figure 1A). There was no difference in rates of occlusion or time to occlusion between the two UCSEMS models. AE rates were significantly higher after UCSEMS placement (32.9% vs. 14.3%, p = 0.03) as was need for unplanned reintervention (29.0% vs. 5.7%, p = 0.004), largely driven by SEMS occlusion (28.9% vs. 2.9%, P = 0.001) in the setting of tissue ingrowth (42/44 cases). A similar number of patients underwent surgical resection (UCSEMS 55.9% vs. FCSEMS 65.7%, p = 0.29) at similar interval after stent placement (UCSEMS 7.0 vs. FCSEMS 6.0 months, p=0.57). All-cause mortality and duration of survival was not different between the two groups (Figure 1B). Conclusion: FCSEMS were associated with longer patency times and fewer interventions in a cohort of patients with LAPC that otherwise exhibited similar survival and rates of surgical intervention. Additional studies are needed to evaluate cost implications, but this data suggests placement of a FCSEMS may be preferred to UCSEMS in the palliation of dMBO in anatomically amenable patients with LAPC.Figure 1.: Cumulative patency time. Stent patency was defined as the interval between the time of stent insertion and the time of biliary reintervention because of stent dysfunction or the end of the follow-up. Patients without stent obstruction were censored at the time of surgery, last follow-up or death. 1B: Overall survival Table 1. - Clinical outcomes of patients who underwent metal biliary stent placement for the management of locally advanced pancreatic cancer UCSEMS n=152 FCSEMS n=35 P Value Clinical Success 140 (92.1) 34 (97.1) 0.29 Adverse Events 50 (32.9) 5 (14.3) 0.03 Stent Occlusion 44 (28.9) 1 (2.9) 0.001 PEP 8 (5.3) 2 (5.7) 1.00 Stent Migration 3 (2.0) 2 (5.7) 0.24 Cholecystitis 1 (0.7) 0 (0.0) 1.00 Unplanned reintervention 44 (29.0) 2 (5.7) 0.004 Median time to unplanned reintervention (months) 4.4 (3.0-5.6) 4.3 (3.6-5.1) 0.81 Median time to stent occlusion (months) 4.4 (3.0-5.6) 5.9 (5.9-5.9) 0.73 Median stent dwell time (months) 7.0 (5.0-8.7) 6.0 (3.5-8.5) 0.16 Median follow up time (months) 15.6 (8.8-24.6) 22.4 (8.3-27.9) 0.23 Surgical resection 85 (55.9) 23 (65.7) 0.29 Median time to surgical resection (months) 7.0 (5.0-8.9) 6.0 (4.4-8.2) 0.57 Death 84 (55.3) 22 (62.9) 0.41 Values are presented as median (IQR) or n (%). UCSEMS uncovered self-expandable metal stent FCSEMS fully covered self-expandable metal stent PEP post-ERCP pancreatitis.

Stent placement by EUS or ERCP for primary biliary decompression in pancreatic cancer: a randomized trial (with videos)

Studies on EUS-guided transmural biliary drainage (EUS-BD) have evaluated its efficacy as a rescue technique after failed ERCP. We performed a single-center, single-blind, randomized trial to compare EUS-BD and ERCP as primary treatment for distal biliary obstruction in pancreatic cancer. Patients underwent EUS-BD (n= 33) or ERCP (n= 34). The primary endpoint was the rate of adverse events. Secondary endpoints were technical success, treatment success (defined as decline in serum bilirubin by 50% at a 2-week follow-up), reinterventions, and intraoperative technical outcome, when applicable. Follow-up was until death or a minimum of 6 months. The rates of adverse events were 21.2% (6.1% moderate severity; others mild severity) in the EUS-BD group and 14.7% (5.9% moderate severity; others mild severity) in the ERCP group (risk ratio, .69; 95% confidence interval, .24-1.97; P= .49). There were no procedure-related deaths. There was no significant difference in the rates of technical success (90.9% vs 94.1%, P= .67), treatment success (97% vs 91.2%, P= .61), or reinterventions (3.0% vs 2.9%, P= .99) between EUS-BD and ERCP cohorts, respectively. The endoscopic interventions did not impede subsequent pancreaticoduodenectomy that was performed in 5 of 33 patients (15.2%) in the EUS-BD and 5 of 34 patients (14.7%) in the ERCP group (P= .99). Given the similar rates of adverse events and treatment outcomes in this randomized trial, EUS-BD is a practical alternative to ERCP for primary biliary decompression in pancreatic cancer. (Clinical trial registration number: NCT03054987.).

International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs. choledochoduodenostomy approaches.

Background and study aims: Endoscopic ultrasound-guided biliary drainage (EUS-BD) can be performed entirely transgastrically (hepatogastrostomy/EUS-HG) or transduodenally (choledochoduodenostomy/EUS-CDS). It is unknown how both techniques compare. The aims of this study were to compare efficacy and safety of both techniques and identify predictors of adverse events. Patients and methods: Consecutive jaundiced patients with distal malignant biliary obstruction who underwent EUS-BD at multiple international centers were included. Technical/clinical success, adverse events, stent complications, and survival were assessed. Results: A total of 121 patients underwent EUS-BD (CDS 60, HG 61). Technical success was achieved in 112 (92.56 %) patients (EUS-CDS 93.3 %, EUS-HG 91.8 %, P = 0.75). Clinical success was attained in 85.5 % of patients who underwent EUS-CDS group as compared to 82.1 % of patients who underwent EUS-HG (P = 0.64). Adverse events occurred more commonly in the EUS-HG group (19.67 % vs. 13.3 %, P = 0.37). Both plastic stenting (OR 4.95, 95 %CI 1.41 – 17.38, P = 0.01) and use of non-coaxial electrocautery (OR 3.95, 95 %CI 1.16 – 13.40, P = 0.03) were independently associated with adverse events. Length of hospital stay was significantly shorter in the CDS group (5.6 days vs. 12.7 days, P < 0.001). Mean follow-up duration was 151 ± 159 days. The 1-year stent patency probability was greater in the EUS-CDS group [0.98 (95 %CI 0.76 – 0.96) vs 0.60 (95 %CI 0.35 – 0.78)] but overall patency was not significantly different. There was no difference in median survival times between the groups (P = 0.36) Conclusions: Both EUS-CDS and EUS-HG are effective and safe techniques for the treatment of distal biliary obstruction after failed ERCP. However, CDS is associated with shorter hospital stay, improved stent patency, and fewer procedure- and stent-related complications. Metallic stents should be placed whenever feasible and non-coaxial electrocautery should be avoided when possible as plastic stenting and non-coaxial electrocautery were independently associated with occurrence of adverse events.