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.

Predictive factors for the failure of endoscopic stent-instent self-expandable metallic stent placement to treat malignant hilar biliary obstruction

AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents(SEMSs). METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography(ERCP) procedures between the two groups.RESULTS The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices(ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve(sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell. CONCLUSION A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.

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.

Treatment of malignant gastric outlet obstruction with endoscopically placed self-expandable metal stents

Malignant gastroduodenal obstruction can occur in up to 20%of patients with primary pancreatic,gastric or duodenal carcinomas.Presenting symptoms include nausea,vomiting,abdominal distention,pain and decreased oral intake which can lead to dehydration, malnutrition,and poor quality of life.Endoscopic stent placement has become the primary therapeutic modality because it is safe,minimally invasive,and a cost-effective option for palliation.Stents can be successfully deployed in the majority of patients. Stent placement appears to lead to a shorter time to symptomatic improvement,shorter time to resumption of an oral diet,and shorter hospital stays as compared with surgical options.Recurrence of the obstructive symptoms resulting from stent occlusion,due to tumor ingrowth or overgrowth,can be successfully treated with repeat endoscopic stent placement in the majority of the cases.Both endoscopic stenting and surgical bypass are considered palliative treatments and,to date,no improvement in survival with either modality has been demonstrated.A tailored therapeutic approach,taking into consideration patient preferences and involving a multidisciplinary team including the therapeutic endoscopist,surgeon,medical oncologist, radiation therapist,and interventional radiologist, should be considered in all cases.

Comparison of endoscopic stenting for malignant biliary obstruction: A single-center study

AIM: To evaluate the efficacy and safety of single-step endoscopic placement of self-expandable metallic stents(SEMS) for treatment of obstructive jaundice.METHODS: A retrospective study was performed among 90 patients who underwent transpapillary biliary metallic stent placement for malignant biliary obstruction(MBO) between April 2005 and October 2012. The diagnosis of primary disease and MBO was based on abdominal ultrasound, computed tomography, magnetic resonance imaging, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography with brush cytology, biopsy, and/or a combination of these modalities. The type of SEMS(covered or non-covered, 8 mm or 10 mm in diameter) was determined by the endoscopist. Ninety patients were divided into two groups: group 1(49 patients) who underwent a singlestep SEMS placement and group 2(41 patients) who underwent a two-step SEMS placement. The technical success rate, complication rate, stent patency, and patient survival rate were compared between the groups. In addition, to identify the clinical prognostic factors associated with patient survival, the following variables were evaluated in Cox-regression analysis: gender, age, etiology of MBO(pancreatic cancer or nonpancreatic cancer), clinical stage(Ⅳb; with distant metastases or Ⅳa >; without distant metastases), chemotherapy(with or without), patency of the stent, and the use of single-step or two-step SEMS. RESULTS: Immediate technical success was achieved in 93.9%(46/49) in group 1 and in 95.1%(39/41) in group 2, with no significant difference(P = 1.0). Similarly, there was no difference in the complication rates between the groups(group 1, 4.1% and group 2, 4.9%; P = 0.62). Stent failure was observed in 10 cases in group 1(20.4%) and in 16 cases in group 2(39.0%). The patency of stent and patient survival revealed no difference between the two groups with Kaplan-Meier analysis, with a mean patency of 111 ± 17 d in group 1 and 137 ± 19 d in group 2(P = 0.91), and a mean survival of 178 ± 35 d in group 1 and 222 ± 23 d in group 2(P = 0.57). On the contrary, the number of days of hospitalization associated with first-time SEMS placement in group 1 was shorter when compared with that number in group 2(28 vs 39 d; P < 0.05). Multivariate analysis revealed that a clinical stage of Ⅳa >(P = 0.0055), chemotherapy(P = 0.0048), and no patency of the stent(P = 0.011) were independent prognostic factors associated with patient survival.CONCLUSION: Our results showed that single-step endoscopic metal stent placement was safe and effective for treating obstructive jaundice secondary to various inoperable malignancies.

Use of endoscopic ultrasound-guided gallbladder drainage as a rescue approach in cases of unsuccessful biliary drainage

This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.

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.

Angle of covered self-expandable metallic stents after placement is a risk factor for recurrent biliary obstruction

BACKGROUND Studies have shown that covered self-expandable metallic stents(CSEMS)with a low axial forces after placement can cause early recurrent biliary obstruction(RBO)due to precipitating sludge formation.AIM To ascertain whether the angle of CSEMS after placement is a risk factor for RBO in unresectable distal malignant biliary obstruction(MBO).METHODS Between January 2010 and March 2019,261 consecutive patients underwent selfexpandable metallic stent insertion by endoscopic retrograde cholangiopancreatography at our facility,and 87 patients were included in this study.We evaluated the risk factors for RBO,including the angle of CSEMS after placement as the primary outcome.We measured the obtuse angle of CSEMS after placement on an abdominal radiograph using the SYNAPSE PACS system.We also evaluated technical and functional success,adverse events,time to RBO(TRBO),non-RBO rate,survival time,cause of RBO,and reintervention procedure as secondary outcomes.RESULTS We divided the patients into two cohorts based on the presence or absence of RBO.The angle of CSEMS after placement(per 1°and per 10°)was evaluated using the multivariate Cox proportional hazard analysis,which was an independent risk factor for RBO in unresectable distal MBO[hazard ratio,0.97 and 0.71;95%confidence interval(CI):0.94-0.99 and 0.54-0.92;P=0.01 and 0.01,respectively].For early diagnosis of RBO,the cut-off value of the angle of CSEMS after placement using the receiver operating characteristic curve was 130°[sensitivity,50.0%;specificity 85.5%;area under the curve 0.70(95%CI:0.57-0.84)].TRBO in the<130°angle group was significantly shorter than that in the≥130°angle group(P<0.01).CONCLUSION This study suggests that the angle of the CSEMS after placement for unresectable distal MBO is a risk factor for RBO.These novel results provide pertinent information for future stent management.

Cholangiocarcinoma and malignant bile duct obstruction: A review of last decades advances in therapeutic endoscopy

In the last decades many advances have been achieved in endoscopy, in the diagnosis and therapy of cholangiocarcinoma, however blood test, magnetic resonance imaging, computed tomography scan may fail to detect neoplastic disease at early stage, thus the diagnosis of cholangiocarcinoma is achieved usually at unresectable stage. In the last decades the role of endoscopy has moved from a diagnostic role to an invaluable therapeutic tool for patients affected by malignant bile duct obstruction. One of the major issues for cholangiocarcinoma is bile ducts occlusion, leading to jaundice, cholangitis and hepatic failure. Currently, endoscopy has a key role in the work up of cholangiocarcinoma, both in patients amenable to surgical intervention as well as in those unfit for surgery or not amenable to immediate surgical curative resection owing to locally advanced or advanced disease, with palliative intention. Endoscopy allows successful biliary drainage and stenting in more than 90% of patients with malignant bile duct obstruction, and allows rapid reduction of jaundice decreasing the risk of biliary sepsis. When biliary drainage and stenting cannot be achieved with endoscopy alone, endoscopic ultrasound-guided biliary drainage represents an effective alternative method affording successful biliary drainage in more than 80% of cases. The purpose of this review is to focus on the currently available endoscopic management options in patients with cholangiocarcinoma.

Biliary metal stents should be placed near the hilar duct in distal malignant biliary stricture patients

BACKGROUND Endoscopic biliary drainage using a self-expandable metallic stent(SEMS)has been widely performed to treat distal malignant biliary obstruction(DMBO).However,the optimal position of the stent remains unclear.AIM To determine the ideal position for SEMS placement.METHODS In total,135 DMBO patients underwent SEMS(uncovered or covered)placement over a ten-year period.A total of 127 patients with biliary obstruction between the junction of the cystic duct and Vater’s papilla were enrolled.An SEMS was placed through the upper common bile duct 2 cm from the biliary hilar duct in 83 patients(Hilar group)or near the top of the biliary obstruction in 44 patients(Lower group).Technical and functional success,adverse events,and risk factors for SEMS dysfunction were evaluated.RESULTS The stent patency period was significantly longer in the Hilar group than in the Lower group(P value<0.01).In multivariate analysis,the only statistically significant risk factor for SEMS dysfunction was being in the Lower group(hazard ratio:9.94,95%confidence interval:2.25–44.0,P<0.01).CONCLUSION A longer patency period was achieved by positioning the SEMS near the biliary hilar duct.

Clinical management for malignant afferent loop obstruction

Afferent loop obstruction(ALO)is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy.With advances in chemotherapy,the incidence of malignant ALO is increasing.Malignant ALO can be complicated by ischemia,gangrenous bowel,pancreatitis,and ascending cholangitis.Moreover,the general condition of patients with recurrent cancer is often poor.Therefore,accurate and rapid diagnosis and minimally invasive treatments are required.However,no review articles on the diagnosis and treatment of malignant ALO have been published.Through literature searching,we reviewed related articles published between 1959 and 2020 in the PubMed database.Herein,we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives.Endoscopic transluminal self-expandable metal stent(SEMS)placement is considered the standard treatment for malignant ALO,as this procedure is well established and less invasive.However,with the development of interventional endoscopic ultrasound(EUS)in recent years,the usefulness of EUS-guided gastrojejunostomy has been reported.Moreover,through indirect comparison,this approach has been reported to be superior to transluminal SEMS placement.It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.

Successful biliary drainage using a metal stent through the gastric stoma

We report a case of biliary drainage for malignant stricture using a metal stent with an ultrathin endoscope through the gastric stoma. A 78-year-old female was referred to our hospital for jaundice and fever. She had undergone percutaneous endoscopic gastrostomy(PEG) for esophageal obstruction after radiation therapy for cancer of the pharynx. Abdominal contrast-enhanced computed tomography showed a 3-cm enhanced mass in the middle bile duct and dilatation of the intrahepatic bile duct. We initially performed endoscopic retrograde cholangiopancreatography(ERCP) with a trans-oral approach. However, neither the side-viewing endoscope nor the ultrathin endoscope passed through the esophageal orifice. Thus, we eventually performed ERCP via the PEG stoma using an ultrathin endoscope. We performed biliary drainage with a 6F introducer selfexpanding metal stent. The cytology findings obtained by brush cytology showed malignancy. Her laboratory results were restored to normal levels after drainage and no complication occurred.

一体式可回收胆管内塑料支架在恶性胆道疾病中的应用效果

目的探讨一体式可回收胆管内塑料支架在恶性胆道梗阻疾病治疗中的应用时效性和安全性。方法回顾性收集2019年1月-2022年5月于该院行内镜逆行胰胆管造影术(ERCP)治疗的恶性胆道梗阻患者81例。其中,25例置入一体式可回收胆管内塑料支架(一体支架组),23例置入普通塑料支架(普通支架组),33例置入金属覆膜支架(金属支架组)。比较3组患者的肝功能变化、支架通畅时间、反流发生率、术后胰腺炎发生率、单次住院时间和住院费用。结果3组患者置入支架前肝功能比较,差异无统计学意义(P>0.05);一体支架组和金属支架组较普通支架组总胆红素(TBIL)、直接胆红素(DBIL)指标下降趋势更为明显,且一体支架组DBIL指标下降程度较金属支架组明显(P<0.05)。金属支架组支架通畅时间最长,为(184.70±16.40)d,一体支架组次之,为(118.64±16.00)d,普通支架组通畅时间最短,为(96.43±15.85)d,3组患者比较,差异有统计学意义(P<0.05)。一体支架组反流发生率最低,金属支架组其次,普通支架组反流发生率最高,3组患者比较,差异有统计学意义(P<0.05)。3组患者胰腺炎发生率和单次住院时间比较,差异均无统计学意义(P>0.05)。金属支架组住院费用较一体支架组和普通支架组高,3组患者比较,差异有统计学意义(P<0.05)。结论相比金属覆膜支架和普通塑料支架,一体式可回收胆管内塑料支架置入术后,肝功能恢复较好,支架通畅时间相对较长,反流发生率较低,住院费用少,且安全有效,是恶性胆道梗阻患者的最优选择。

胃出口梗阻的诊疗进展

胃出口梗阻也称幽门阻塞或狭窄,是指由于十二指肠、胃远端、幽门管、幽门前区机械压迫或阻塞引起的幽门狭窄,患者会出现胃内容物不能通过的现象,并可伴有恶心、呕吐、腹痛和食欲减退等相关症状,这大大降低了患者的生命质量,对个体影响极大,危害程度极高,科学治疗该病具有极其重要的社会意义。根据胃出口梗阻的发病机制,本文就其临床诊断情况以及治疗策略作一综述,从而为胃出口梗阻的诊疗情况提供一定的参考。

肠道支架置入治疗结直肠恶性梗阻的疗效观察

目的探讨经结肠镜及X线下置入钛镍记忆合金支架治疗结直肠恶性梗阻的安全性与临床疗效。方法选择19例结直肠癌患者作为实验组,其中5例结直肠恶性梗阻并有手术指征的患者接受临时支架置入术;14例无手术指征的结直肠恶性梗阻患者接受永久性支架置入术姑息治疗。选择同期外科19例结直肠癌并梗阻的患者作为对照组,观察治疗组支架植入成功率和梗阻改善情况及两组患者生活质量及生存时间。结果与对照组结果相比,实验组支架放置成功率为100%,肠道梗阻均有缓解,生活质量明显改善,而平均生存时间相当,差异无显著性(P>0.05)。结论结肠镜及X线下置入钛镍记忆合金支架治疗结直肠癌恶性梗阻是一种简单可行、安全有效、并发症少的临时性或永久姑息性治疗手段,能减轻患者痛苦、提高生活质量、与外科手术的平均生存时间相当。

恶性阻塞性黄疸临床分析153例

目的:评价经皮经肝穿刺胆道内置管引流术(PTCD)在恶性阻塞性黄疸(MBOJ)患者中的临床诊断及其治疗价值.方法:回顾性分析我院1995-03/2008-03收治153例MBOJ患者的临床资料.A组采用xPTCD并成功放置可膨胀性胆道金属内支架(EMS)治疗MBOJ患者27例;B组采用uPTCD治疗75例;C组选择uPTCD/xPTCD外引流及内窥镜下胆道内塑料或金属支架置入内引流术(ERBD/EMBE)内引流治疗16例;D组35例MBOJ选择PTCD及ERBD/EMBE内引流1wk-4mo后剖腹探查手术.结果:A组第1、2、3及4次以上置管成功率66.7%,76.7%,83.3%及100%;患者0.5、1及3年生存率分别为52.6%,15.8%及0%;B组置管成功率较A组明显提高(P<0.01),其第1及2次置管成功率88.7%及100%,0.5、1及3年生存率分别为47.7%,21.5%及0%;C组术后胆道感染、急性胰腺炎等并发症发生率较高为68.8%(P<0.01),0.5、1及3年生存率分别为53.8%,23.1%及0%;D组术后生存率较其他组明显延长(P<0.01),0.5、1、3及5年生存率分别为77.8%、66.7%、18.5%及14.8%.结论:PTCD/ERBD/EMBE是手术不能根治的恶性胆道梗阻较为有效的姑息性治疗方法,uPTCD对于晚期MBOJ患者术前定位定性诊断、术前减黄以改善肝功能及姑息性治疗方面均具有重要的临床价值.

内镜下胆道金属支架置入联合鼻胆管引流治疗恶性梗阻性黄疸

目的探讨经内镜胆道金属支架置入术(EBMSD)联合鼻胆管引流术(ENBD)治疗恶性梗阻性黄疸的疗效。方法回顾2009年1月至2010年3月采用内镜逆行胰胆管造影术(ERCP)并留置胆道金属支架,同时联合ENBD治疗的恶性梗阻性黄疸患者共17例,并对疗效、鼻胆管引流情况及术后并发症进行分析。结果 17例恶性梗阻性黄疸患者,行ERCP操作22例次,一次置管成功21例次,操作成功率95.45%。术后1周黄疸明显消退,肝功能改善,生活质量提高。术后2例患者鼻胆管引出血性胆汁、6例患者胆汁引流不畅,通过对症处理恢复正常。17例患者中仅2例术后发生高淀粉酶血症,无出血、穿孔、急性胰腺炎、胆管炎发生。结论胆道金属支架置入联合鼻胆管引流具有创伤小、并发症少、疗效确切、重复性强、方便观察、术后恢复快的特点,成为目前治疗恶性梗阻性黄疸的重要姑息性治疗手段。

金属内支架对45例胃十二指肠恶性梗阻的治疗

目的:探讨不能手术切除的胃十二指肠恶性梗阻介入治疗的临床价值。方法:45例患者均有明显的梗阻症状,其中胃窦及幽门梗阻17例(37.8%),十二指肠梗阻22例(48.9%),胃十二指肠吻合口梗阻6例(13.3%)。在X线透视监视下,经口腔置入自膨式金属内支架47枚,并对13例患者支架术后1～2周行局部动脉灌注化疗。结果:45例患者中44例一次成功置放支架,一次性技术成功率为97.8%。支架置入后梗阻症状缓解,当日即能进软食,无严重并发症发生。随访时间2～15个月,患者平均生存5.5个月。结论:对于不能或拒绝手术的胃十二指肠恶性梗阻的患者,金属内支架置入是简单、有效、安全、创伤小的治疗方法。

经内镜放置自膨式不带膜金属支架治疗胆管中下段恶性狭窄的疗效观察

目的 观察经内镜放置不带膜自膨式金属支架治疗胆管中下段恶性狭窄的效果。方法 对我院收治的晚期恶性肿瘤伴阻塞性黄疸且无法切除的 16例患者采用内镜置入不带膜自膨式金属支架治疗的结果进行回顾性分析。结果 15例 (94 % )成功置入不带膜自膨式金属支架 ,内引流通畅 ,置入不带膜自膨式金属支架后 7d及14d复查肝功能和B超 ,总胆红素、直接胆红素、转氨酶均较治疗前明显降低 (P<0 .0 1) ,胆总管直径明显变细 (P<0 .0 1)。其中 6例 3周内恢复正常。早期并发症 (置入不带膜金属支架后 7d内 ) :1例出现轻度急性胰腺炎 ,1例出现急性胆管炎 ,经抗感染及对症治疗后好转。平均存活时间为 186 .93d(5 4～ 4 2 6d) ,平均支架引流有效期为15 6d(5 1～ 4 2 6d) ,有 3例 (2 0 % )发生支架堵塞。结论 经内镜放置不带膜自膨式金属支架是治疗胆管中下段恶性狭窄的较理想方法。