Feasibility and Safety of Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) for Malignant Biliary Obstruction Associated with Ascites: Results of a Pilot Study.

BACKGROUND: It has been suggested that EUS-BD may be a feasible and safer alternative to percutaneous transhepatic biliary drainage (PTBD) after failed ERCP in patients with ascites. To date, no study has specifically evaluated the performance of EUS-BD in this context. METHODS: Retrospective analysis was done for patients with and without ascites who underwent EUS-BD for malignant biliary obstruction after failed ERCP between July 2010 and September 2014. Complications and technical and clinical successes between the two groups were compared. RESULTS: A total of 31 patients were included: 20 patients without ascites (group 1) and 11 with ascites (group 2). Nineteen patients underwent EUS-hepaticogastrostomy (six in group 2), and 12 underwent EUS-choledochoduodenostomy (five in group 2). Technical success was achieved in all patients. Clinical success was observed in 95% (n = 19) in group 1 and 64% (n = 7) in group 2 (p = 0.042). In three out of four patients without clinical success in group 2, the follow-up period was not long enough to observe the clinical response because of early death within the 2 weeks after EUS-BD secondary to disease progression or preprocedural unresponsive sepsis. No significant differences were observed between groups 1 and 2 either in the overall rates of procedural-related complications (20 and 9%, respectively, p = 0.63) or in the rates of major complications (15 vs 9%, respectively, p = 0.639). Stent migration occurred in one patient in each group, intra- or post-procedural bleeding occurred in two patients in group 1, which was conservatively managed, and one patient in group 1 presented biliary leakage. Stent patency and the number of re-interventions were not significantly different. CONCLUSIONS: EUS-BD is technically feasible in patients with ascites. Our results suggest that EUS-BD may be a clinically effective and safe alternative after failed ERCP in patients with ascites.

Similar performance but higher cholecystitis rate with covered biliary stents: results from a prospective multicenter evaluation.

BACKGROUND AND STUDY AIMS: Endoscopic biliary stenting is now a well-established treatment method in patients with unresectable malignant biliary obstruction. Despite advances with metal stents, the problem of stent occlusion has not yet been resolved. Covered metal stents could reduce the occlusion rate by preventing tumor ingrowth, but have not been well evaluated. A prospective multicenter study was therefore conducted to evaluate the efficacy and disadvantages of covered Wallstents. PATIENTS AND METHODS: Covered Wallstents were implanted endoscopically in 62 patients with inoperable distal malignant biliary obstruction. Complications, stent patency, and patient survival were analyzed. RESULTS: Stent insertion was achieved in 61 of the 62 patients (98.4 %). Procedure-related complications were observed in four patients, consisting of minor pancreatitis (n = 2) and abdominal pain due to stent expansion (n = 2). There was no procedure-related mortality. Seven patients died too early for proper assessment, so that a total of 54 patients were ultimately evaluated. Stent dysfunction occurred in 17 of the 54 patients (31.5 %). The reasons for dysfunction were proximal tumor overgrowth (n = 5), migration (n = 3), lithiasis or food impaction (n = 3), cholangitis without the need for a repeat biliary intervention (n = 5), and unknown (n = 1). The median period of stent patency was 142 days. No tumor ingrowth was observed. Acute cholecystitis was diagnosed in five patients (10 %) and was responsible for one death. Three stents were successfully removed. CONCLUSIONS: Covered biliary metal stents are effective for the drainage of distal malignant biliary obstruction, with a dysfunction rate apparently similar to that of uncovered stents. However, the risk of acute cholecystitis appears to be a major concern with this type of stent in patients with gallbladder in situ. Further comparative studies are needed.

Esophageal capsule endoscopy versus esophagogastroduodenoscopy for evaluating portal hypertension: a prospective comparative study of performance and tolerance.

BACKGROUND AND STUDY AIMS: Esophagogastroduodenoscopy (EGD) is the most effective method for examining the upper gastrointestinal tract, and particularly for evaluating portal hypertension in cirrhotic patients, especially for screening purposes. The aim of this study was to assess the feasibility, safety, accuracy, and tolerance of PillCam ESO capsule endoscopy for this indication. PATIENTS AND METHODS: In this prospective study, unsedated EGD and capsule endoscopy examinations were conducted on the same day in cirrhotic patients at the time of diagnosis. The patients quantified the tolerability (relative to pain, nausea, choking sensations, etc.) of the two procedures using a 100-mm visual analogue scale. The time required for the recording and for diagnosis with the capsule examination were documented, as were the patients' preferences in comparison with EGD. Two independent endoscopists blinded to the EGD diagnoses assessed the diagnostic accuracy of the images obtained. RESULTS: Twenty-one patients were included in the study (mean age 62, mean Model for End-Stage Liver Disease score 10.5, mean Child-Pugh score 7.3). The procedure was safe. One patient was unable to swallow the capsule. The mean recording time was 213 s (range 6 - 1200 s); the procedure accurately assessed the presence or absence of esophageal varices in 16 of 19 patients (84.2 %); and it correctly indicated a need for primary prophylaxis (esophageal varices of grade 2 or more and/or red signs) in 100 % of cases. The tolerability of the capsule endoscopy examination was significantly better, and all of the patients preferred capsule endoscopy to EGD (which was transnasal in 11 patients). CONCLUSIONS: Capsule endoscopy was feasible, safe, accurate, highly acceptable, and preferred by cirrhotic patients undergoing screening for portal hypertension. This new technique requires further and more extensive evaluation, as well as assessment of its cost-effectiveness.