Endoscopic biliary treatment of unresectable cholangiocarcinoma: A meta-analysis of survival outcomes and systematic review

BACKGROUND Endoscopic radiofrequency ablation(ERFA),percutaneous radiofrequency ablation(PRFA),and photodynamic therapy(PDT),when used in conjunction with conventional biliary stenting,have demonstrated a survival benefit in patients with unresectable cholangiocarcinoma.AIM To compare pooled survival outcomes,adverse event rates,and mean stent patency for those undergoing these procedures.METHODS A comprehensive literature review of published studies and abstracts from January 2011 to December 2020 was performed comparing survival outcomes in patients undergoing ERFA with stenting,biliary stenting alone,PRFA with stenting,and PDT with stenting for unresectable cholangiocarcinoma(CCA).RESULTS Data from four studies demonstrated a pooled mean survival favoring ERFA as compared to biliary stenting alone(12.0±0.9 mo vs 6.8±0.3 mo,P<0.001)as well as statistically improved median survival time(13 mo vs 8 mo,P<0.001).Both ERFA with stenting and PRFA with stenting groups demonstrated statistical superiority to biliary stenting alone(P<0.001 and P=0.004,respectively).However,when comparing ERFA to PRFA,pooled data demonstrated overall higher mean survival in the ERFA with stenting cohort as compared to PRFA with stent cohort(12.0+0.9 mo vs 8.1+2.1 mo,P<0.0001).Data from two studies demonstrated a pooled median survival favoring ERFA with stenting as compared to PDT with stenting(11.3 mo vs 8.5 mo,P=0.02).CONCLUSION While further prospective,randomized studies are needed to assess efficacy of ERFA,our metaanalysis demonstrated that this technique offers endoscopists a reasonable palliative method by which to treat patients with unresectable CCA that results in longer survival as compared to biliary stenting alone,percutaneous radiofrequency ablation with biliary stenting,and PDT with biliary stenting as well as an acceptable adverse event profile based on available published data.

Practice patterns in FNA technique: A survey analysis

AIM: To ascertain fine needle aspiration(FNA) tech-niques by endosonographers with varying levels of ex-perience and environments.METHODS: A survey study was performed on United States based endosonographers. The subjects complet-ed an anonymous online electronic survey. The main outcome measurements were differences in needle choice, FNA technique, and clinical decision making among endosonographers and how this relates to years in practice, volume of EUS-FNA procedures, and prac-tice environment.RESULTS: A total of 210(30.8%) endosonographers completed the survey. Just over half(51.4%) identified themselves as academic/university-based practitioners. The vast majority of respondents(77.1%) identified themselves as high-volume endoscopic ultrasound(EUS)(> 150 EUS/year) and high-volume FNA(> 75 FNA/year) performers(73.3). If final cytology is non-diagnostic, high-volume EUS physicians were more likely than low volume physicians to repeat FNA with a core needle(60.5% vs 31.2%; P = 0.0004), and low volume physicians were more likely to refer patients for either surgical or percutaneous biopsy,(33.4% vs 4.9%, P < 0.0001). Academic physicians were more likely to repeat FNA with a core needle(66.7%) compared to community physicians(40.2%, P < 0.001). CONCLUSION: There is significant variation in EUS-FNA practices among United States endosonographers. Differences appear to be related to EUS volume and practice environment.