Endoscopic ultrasound‐guided gallbladder and bile duct drainage with lumen apposing metal stent: A large multicenter cohort (with videos)

Abstract

Background and AimCholecystectomy and endoscopic retrograde cholangiopancreatography are the gold standard for managing acute cholecystitis and malignant biliary obstruction, respectively. Recent advances in therapeutic endoscopic ultrasound (EUS) have provided alternatives for managing patients in whom these approaches fail, namely, EUS‐guided gallbladder drainage (EUS‐GB) and EUS‐guided bile duct drainage (EUS‐BD). We aimed to assess the technical and clinical success of these techniques in the largest multicenter cohort published to date.MethodsA retrospective, multicenter, observational study involving 17 centers across Australia and New Zealand was conducted. All patients who had EUS‐GB or EUS‐BD performed in a participating center using a lumen apposing metal stent between 2016 and 2020 were included. Primary outcome was technical success, defined as intra‐procedural successful drainage. Secondary outcomes included clinical success and 30‐day mortality.ResultsOne hundred and fifteen patients underwent EUS‐GB (n = 49) or EUS‐BD (n = 66). EUS‐GB was technically successful in 47 (95.9%) while EUS‐BD was successful in 60 (90.9%). All failed cases were due to maldeployment of the distal flange outside of the targeted lumen. Clinical success of EUS‐GB was achieved in 39 (79.6%). No patients required subsequent cholecystectomy. Clinical success of EUS‐BD was achieved in 52 (78.8 %). Thirty‐day mortality was 14.3% for EUS‐GB and 12.1% for EUS‐BD.ConclusionsEUS‐guided gallbladder drainage and EUS‐BD are promising alternatives for managing nonsurgical candidates with cholecystitis and malignant biliary obstruction following failed endoscopic retrograde pancreatography. Both techniques delivered high technical success with acceptable clinical success. Further research is needed to investigate the gap between technical and clinical success.

Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: A systematic review focusing on issues and rescue management

“…The type of misdeployment was not properly described in 31 (45.6%) EUS-CDS. Seven other causes of technical failure were reported in four studies[ 15 , 22 , 24 , 38 ]: 1 massive bleeding, 1 inability to puncture the bile duct, 2 duodenal perforations, 1 failure of fistula creation, 1 mechanical failure and 1 patient intolerance. In three studies[ 31 , 33 , 37 ], the effective rescue therapy after LAMS misdeployment was considered a technical success by the authors and in one study[ 15 ] duodenal perforation during dilation of the fistulous tract was the cause of technical failure.…”

“…We identified 213 studies using our search strategy; 185 studies were excluded since they did not meet inclusion criteria. A total of 28 studies reported cases of EUS-GBD[ 8 , 22 , 29 , 37 , 40 - 63 ] including 16 studies in which LAMS misdeployment occurred[ 22 , 29 , 50 - 63 ]. The study flow chart is shown in Figure 2 .…”

“…Only 8 studies reported if the GB was accessed from the stomach ( n = 7/11, 63.6%) or duodenum ( n = 4/11, 36.4%)[ 22 , 51 - 55 , 59 , 61 ]. The misdeployment of the proximal flange occurred in 9/25 (36%) cases, while the distal flange was misdeployed in 16/25 (64%) cases.…”

Outcomes of endoscopic ultrasound‐guided gastro‐enterostomy for gastric outlet obstruction in a two‐centre Australian Cohort (with video)

“…The procedure was performed by a single pancreato-biliary endoscopist (Saurabh Gupta) at both sites who is a highly experienced endosonographer and has previously published 16 Research Ethics and Governance approval of the audit was granted by Adventist HealthCare Limited. Data from electronic medical records was used to determine baseline demographics, etiology and location of the obstruction, and diet tolerability according to the GOO scoring system (0 representing no oral intake, 1 for liquid diet only, 2…”

“…The procedure was performed by a single pancreato‐biliary endoscopist (Saurabh Gupta) at both sites who is a highly experienced endosonographer and has previously published 16 on the use of LAMS in the gallbladder and biliary tract. He is an active member of the EUS special interest group within the Gastroenterology Society of Australia and runs EUS training workshops within Asia Pacific.…”