Combined endoscopic mAnagement of BiliaRy and gastrIc OutLET obstruction (CABRIOLET Study): A multicenter retrospective analysis

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.

Classification, risk factors, and management of lumen apposing metal stent dysfunction during follow‐up of endoscopic ultrasound‐guided choledochoduodenostomy: Multicenter evaluation from the Leuven‐Amsterdam‐Milan Study Group

“…Even after re‐establishing efficient gastroduodenal transit, some accumulation of food remnants and gastric juices in the prestenotic duodenal bulb may intermittently obstruct the LAMS. In line with recent data, patients with a combination of GOO and EUS‐CDS seem at higher risk for LAMS dysfunction, especially in those treated with enteral stents 32 . Alternatives such as EUS‐guided or percutaneous transpapillary stenting or EUS‐HGS may be preferred in these patients 33 …”

“…In line with recent data, patients with a combination of GOO and EUS-CDS seem at higher risk for LAMS dysfunction, especially in those treated with enteral stents. 32 Alternatives such as EUS-guided or percutaneous transpapillary stenting or EUS-HGS may be preferred in these patients. 33 Despite stent dysfunction, EUS-CDS remains an invaluable technique in case of failed/impossible ERCP in distal MBO.…”

Endoscopic ultrasound-guided choledochoduodenostomy using single-step lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-p): a prospective pilot study

“…Second, a relatively strict, though clinically relevant, definition of stent dysfunction was used in the current study, including cholangitis as well as persistent or recurrent jaundice. Third, despite GOO being an exclusion criterion, three patients developed GOO during the course of the disease, which may have contributed to the occurrence of cholangitis [9,18]. Fourth, the use of LAMS with a relatively small diameter (6 × 8 mm) may have contributed, as currently there is some evidence that stents with larger diameters may reduce the risk of stent dysfunction [16].…”

“…Thirdly, despite GOO being an exclusion criterion, 3 patients developed GOO during the course of the disease which may have contributed to the occurrence of cholangitis. [9,18] Fourthly, the use of a relatively small diameter LAMS (6x8mm) may have contributed, as there currently is some evidence that larger diameter stents may reduce the risk of stent dysfunction. [16] Lastly, in our study DPS were not routinely placed through the LAMS while recent data showed that this may be beneficial.…”

EUS-Guided Gastroenterostomy in Malignant Gastric Outlet Obstruction: A Comparative Study between First- and Second-Line Approaches after Enteral Stent Placement

“…This is probably the main reason explaining why the 28% of patients needed a complementary artificial nutrition at the end of follow-up in our study. An increased risk of GOO recurrence with ES versus EUS-GE has been recently described [ 24 ]. Similarly, there was only one patient with an EUS-GE dysfunction in our series (invasion of the stent by peritoneal carcinomatosis, 4%).…”