Endoscopic-ultrasound-guided biliary drainage with placement of electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction:Updated meta-analysis

BACKGROUND Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced(ECE)delivery of lumen-apposing metal stent(LAMS)is gradually being re-cognized as a viable palliative technique for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography(ERCP)failure.However,most of the studies that have assessed its efficacy and safety were small and hetero-geneous.Prior meta-analyses of six or fewer studies that were published 2 years ago were therefore underpowered to yield convincing evidence.AIM To update the efficacy and safety of ECE-LAMS for treatment of biliary ob-struction after ERCP failure.METHODS We searched PubMed,EMBASE,and Scopus databases from the inception of the ECE technique to May 13,2022.Primary outcome measure was pooled technical success rate,and secondary outcomes were pooled rates of clinical success,re-intervention,and adverse events.Meta-analysis was performed using a random-effects model following Freeman-Tukey double-arcsine transformation in R soft-ware(version 4.1.3).RESULTS Fourteen eligible studies involving 620 participants were ultimately included.The pooled rate of technical success was 96.7%,and clinical success was 91.0%.Adverse events were reported in 17.5%of patients.Overall reinter-vention rate was 7.3%.Subgroup analyses showed results were generally consistent.CONCLUSION ECE-LAMS has favorable success with acceptable adverse events in relieving biliary obstruction when ERCP is impossible.The consistency of results across most subgroups suggested that this is a generalizable approach.

Unveiling the potential of electrocautery-enhanced lumen-apposing metal stents in endoscopic ultrasound-guided biliary drainage

This editorial delves into Peng et al's article,published in the World Journal of Gastrointestinal Surgery.Peng et al's meta-analysis investigates the effectiveness of electrocautery-enhanced lumen-apposing metal stents(ECE-LAMS)in ultrasound-guided biliary drainage for alleviating malignant biliary obstruction.Examining 14 studies encompassing 620 participants,the research underscores a robust technical success rate of 96.7%,highlighting the efficacy of ECE-LAMS,particularly in challenging cases which have failed endoscopic retrograde cholangio pancreatography.A clinical success rate of 91.0% underscores its impact on symptom alleviation,while a reasonably tolerable adverse event rate of 17.5% is observed.However,the 7.3% re-intervention rate stresses the need for post-procedural monitoring.Subgroup analyses validate consistent outcomes,bolstering the applicability of ECE-LAMS.These findings advocate for the adoption of ECELAMS as an appropriate approach for biliary palliation,urging further exploration in real-world clinical contexts.They offer valuable insights for optimizing interventions targeting malignant biliary obstruction management.

Outcomes of a single-step endoscopic ultrasound-guided drainage of pancreatic-fluid collections using an electrocautery-enhanced coaxial lumen-apposing,self-expanding metal stent with and without fluoroscopy

Background:Fluoroscopy is often used during the endoscopic drainage of pancreatic-fluid collections(PFCs).An electrocautery-enhanced coaxial lumen-apposing,self-expanding metal stent(ELAMS)facilitates a single-step procedure and may avoid the need for fluoroscopy.This study compares the treatment outcomes using ELAMS with and without fluoroscopy.Methods:Patients with PFCs who had cystogastrostomy from January 2014 to February 2017 were enrolled.Two groups were studied based on fluoroscopy use.Technical success was defined as uneventful insertion of ELAMS at time of procedure.Clinical success was defined as(i)clinical resolution of symptoms after the procedure and(ii)>75%reduction in cyst size on computed tomography 8 weeks after stent placement.Adverse events including bleeding,stent migration,and infection were recorded.Results:A total of 21 patients(13 males)had PFCs drainage with ELAMS in the study period.The mean age was 51.6614.2 years.Thirteen patients had walled-off necrosis while eight had a pancreatic pseudocyst.The mean size of the PFCs was 11.363.3 cm.Fluoroscopy was used in seven cases(33%)and was associated with a longer procedure time compared to non-fluoroscopy(43.1610.4 vs 33.3610.5 min,P=0.025).This association was independent of the size,location,or type of PFCs.Fluoroscopy had no effect on the technical success rates.In fluoroless procedures,the clinical resolution was 91%as compared to 71%in fluoroscopy procedures(P=0.52)and the radiologic resolution was 57%as compared to 71%in fluoroscopy procedures(P=0.65).Three cases of stent migration/displacement occurred in the fluoroless procedures.Conclusions:ELAMS may avoid the need for fluoroscopy during cystogastrostomy.Procedures without fluoroscopy were significantly shorter and fluoroscopy use had no impact on the technical or clinical success rates.

Endoscopic ultrasound-guided biliary drainage using electrocauteryenhanced lumen-apposing metal stent for malignant biliary obstruction:A promising procedure

In this editorial,we comment on the article by Peng et al.Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage.The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound,endoscopic ultrasound(EUS),or both.Endoscopic retrograde cholangiopancreatography(ERCP)has been primarily recommended for the management of biliary obstruction,while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage(PTBD)are alternative choices for cases where ERCP has failed or is impossible.PTBD is limited by shortcomings of a higher rate of adverse events,more reinterventions,and severe complications.EUS-guided biliary drainage has a lower rate of adverse events than PTBD.EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)enables EUS-guided biliaryenteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire.The present meta-analysis showed that ECELAMS has a high efficacy and safety in relieving biliary obstruction in general,although the results of LAMS depending on the site of biliary obstruction.This study has highlighted the latest advances with a larger sample-based comprehensive analysis.

Endoscopic ultrasound-guided biliary drainage after failed endoscopic retrograde cholangiopancreatography: The road is open for almighty biliopancreatic endoscopists!

Commentary on the article written and published by Peng et al,investigating the role of endoscopic ultrasound(EUS)-guided biliary drainage for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiopan-creatography(ERCP).For 40 years endoscopic biliary drainage was synonymous with ERCP,and EUS was used mainly for diagnostic purposes.The advent of therapeutic EUS has revolutionized the field,especially with the development of a novel device such as electrocautery-enhanced lumen-apposing metal stents.Complete biliopancreatic endoscopists with both skills in ERCP and in interven-tional EUS,would be ideally suited to ensure patients the best drainage technique according to each individual situation.

Endoscopic ultrasound-guided biliary drainage: A change in paradigm?

Endoscopic ultrasound-guided biliary drainage(EUS-BD) has been developed as an alternative means of biliary drainage for malignant biliary obstruction(MBO).Compared to percutaneous transhepatic biliary drainage,EUS-BD offers effective internal drainage in a single session in the event of failed endoscopic retrograde cholangiopancreatography and has fewer adverse events(AE). In choosing which technique to use for EUS-BD,a combination of factors appears to be important in decision-making; technical expertise,the risk of AE,and anatomy. With the advent of novel all-in-one EUS-BD specific devices enabling simpler and safer techniques,as well as the growing experience and training of endosonographers,EUS-BD may potentially become a first-line technique in biliary drainage for MBO.