Aims We aimed to evaluate the efficacy and safety of the first endoscopic ultrasound-guided biliary drainage procedures performed in our unit while evaluating the technical and clinical success, procedure time, hospital stay, and adverse events.

Methods A retrospective study was performed between March 2020 and November 2022 in all EUS-BD procedures performed by a single endoscopist in a tertiary referral center.

Results During the study period 112 patients underwent EUS-BD – 104 (92.8%) for malignant disease and 8 (7.14%) for benign. In 47% EUS-BD was chosen as a primary drainage modality without attempting ERCP. In all other cases the procedure was performed after unsuccessful ERCP. Technical success was achieved in 96,6% of the patients, clinical success- in 89,19 %. The medium procedure time was 54,8 min. The mean hospital stay was 5 days. Intraprocedural complications were experienced in 6 cases- 3 of them required conversion to PTBD, performed immediately by the same team. Postprocedural adverse events in the first 7 days were noted in 15 patients (13,5%). Only one required admission in intensive care unit.

Conclusions EUS- BD is a safe and effective procedure to achieve biliary drainage and in many clinical scenarios could be chosen as a primary drainage modality. Lowering the threshold to perform EUS-BD, doing it in the same session when ERCP has failed or as an adjunct to transpapillary drainage demonstrates best results and shortens hospital stay. Mastering PTBD by the same team also improves the outcomes and could avoid fatal complications.

EUS-guided drainage and transgastric endoscopic necrosectomy (TEN) are less invasive options for treating complicated pancreatic necrosis. A 36 y-old man with alcohol-induced necrotizing pancreatitis developed an infected spontaneous pancreatic fluid drainage at his left inguinal site, which turned into a high output (over 1000mL) gastropancreaticocutaneus fistula following EUS-guided drainage and TEN. Successful treatment was obtained with transgastric negative-pressure (vacuum) therapy.

Introduction:

Lumen-apposing metal stents (LAMS) are pivotal in various endoscopic procedures, yet their use is associated with complications in up to 21.3% of cases [1,2]. There is a need for international consensus recommendations to enhance the safety of LAMS usage for both on- and off-label use.

Aims and Methods:

This study formulated evidence-based recommendations on LAMS safety, segregated into categories such as general safety, peripancreatic fluid collections (PFC), biliary drainage (EUS-BD), gallbladder drainage (EUS-GBD), gastroenterostomy (EUS-GE) and gastric access temporary for endoscopy (GATE). The evidence level of each statement was determined using the GRADE methodology. These were subjected to a three-round modified Delphi process by LAMS experts to build consensus. Statements were accepted or revised based on an 80% consensus threshold.

Results:

Out of the 60 drafted statements, 56 (93.3%) were accepted, and 4 (6.6%) were discarded due to insufficient consensus. Consensus was reached on optimal learning paths, preprocedural imaging, airway protection, and essential safety measures during procedures. Specific guidelines were also established for distinct LAMS applications, including patient selection, stent size, and management of LAMS-related complications.

Conclusion:

An international Delphi consensus was developed providing recommendations for the safe usage of LAMS, aiming to serve as a practical guideline for endoscopists to reduce LAMS-related adverse events. We hope that these consensus recommendations provide a practical and evidence-based guideline for endoscopists to minimize adverse events related to their LAMS procedures. 

References: 

1.     Choi, J.H.; Kozarek, R.A.; Larsen, M.C.; Ross, A.S.; Law, J.K.; Krishnamoorthi, R.; Irani, S. Effectiveness and safety of lumen- apposing metal stents in endoscopic interventions for off-label indications. Dig. Dis. Sci. 2021, 67, 2327–2336.

2.     Hindryckx, P.; Degroote, H. Lumen-apposing metal stents for approved and off-label indications: A single-centre experience. Surg. Endosc. 2020, 35, 6013–6020.