1. EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos)

Bang JY et al. Gastrointest Endosc 2018 Aug 15; [e-pub].

Key points:

  • Endoscopic ultrasound–guided celiac plexus neurolysis (EUS-CPN) for palliation of pain in pancreatic cancer is suboptimal;
  • Limited data suggest the effectiveness of EUS-guided radiofrequency ablation (EUS-RFA) of the celiac ganglia for pain relief;
  • American researchers compared the efficacy of the two procedures (EUS-CPN and EUS-RFA) for pain relief in a single-blind, randomized trial;
  • 26 patients (locally advanced or metastatic pancreatic cancer) randomized to undergo EUS-CPN (14) or EUS-RFA (12); Primary outcome: pain severity (standardized scoring instruments – QLQ-PAN26;
  • At 4 weeks: pain scores were significantly lower in the EUS-RFA group; Quality-of-life scores were better in patients submitted to EUS-RFA; No difference in adverse events;
  • The data from this randomized trial shows promising results for EUS-RFA use in pancreatic cancer pain palliation.


Background and Aims: Although frequently performed, the efficacy of endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) for palliation of pain in pancreatic cancer is suboptimal. Recently, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been proposed as a palliative treatment option for pancreatic neoplasms. We performed a single-blind, randomized trial to compare the effectiveness of EUS-CPN and EUS-RFA for palliation of pain in pancreatic cancer.

Methods: Patients with abdominal pain due to locally advanced or metastatic pancreatic cancer underwent EUS-CPN (n=14) or EUS-RFA (n=12). EUS-RFA was performed using a 1F monopolar probe passed via a 19-gauge FNA needle, by targeting the area of celiac plexus or visualized ganglia. Primary outcome was pain severity as measured by the European Organization for Research and Treatment of Cancer(EORTC) pancreatic cancer-specific (QLQ-PAN26) questionnaire administered pre-treatment and at 2 and 4 weeks post-treatment. Secondary outcome measures were comparison of quality of life as determined by PAN26 and C30 (core cancer) questionnaires and opioid analgesia use between the 2 groups

Results: Both the pancreatic cancer-specific (49.0 vs 57.0, p<0.001) and core cancer (51.9 vs 64.4, p=0.032) questionnaires revealed less pain for EUS-RFA over EUS-CPN. Also, EUS-RFA cohort experienced significantly less severe gastrointestinal symptoms, were able to plan more for the future, and had better emotional functioning compared with the EUS-CPN group.

Conclusions: Compared with EUS-CPN, EUS-RFA provided more pain relief and improved the quality of life for patients with pancreaticcancer. ClinicalTrials.gov Identifier: NCT03152487.


2. EUS-guided antegrade intervention for benign biliary diseases in patients with surgically altered anatomy (with videos)

Mukai S et al. Gastrointest Endosc 2018 Aug 1; [e-pub].

Key points:

  • Balloon enteroscopy-assisted ERCP (BE-ERCP) is effective and safe for benign biliary diseases in patients with surgically altered anatomy (SAA), but not allways successful;
  • EUS-guided antegrade intervention (EUS-AI) has been developed for BE-ERCP failure cases but usually reserved for patients with unresectable malignancy;
  • Japanese investigators report the data of a retrospective study in which they examined procedural success of EUS-AI for benign biliary disease (mostly anastomotic strictures or common bile duct stones)in 37 patients with surgically altered biliary anatomy after failed BE-ERCP:
  • 34 patients had hepaticogastrostomy and 3 hepaticojejunostomy: success rate: 92% (most required two procedures); 3 patients developed bile peritonitis (conservative management); Both plastic and metal stents were used
  • This study reveals that EUS-guided bile duct drainage may be safe and effective also for benign biliary diseases with a success rate higher that BE-ERCP.


Background and Aims: Although balloon enteroscopy-assisted ERCP (BE-ERCP) is effective and safe for benign biliary diseases in patients with surgically altered anatomy (SAA), BE-ERCP is not always successful. Recently, EUS-guided antegrade intervention (EUS-AI) including a 1-stage or 2-stage procedure has been developed for BE-ERCP failure cases. The aim of the present study was to evaluate the outcome of EUS-AI for benign biliary diseases with SAA.

Methods: Of 48 patients in whom BE-ERCP failed, percutaneous transhepatic intervention was performed in 11 patients. Another 37 patients who failed BE-ERCP and underwent EUS-AI for benign biliary diseases with SAA [common bile duct stones (n = 11), intrahepatic bile duct stones (n = 5), anastomotic stricture (n = 21)] from November 2013 until November 2017 were retrospectively reviewed.

Results: The overall technical success of the creation of hepaticoenteric tract by EUS was 91.9% (34/37). Moderate adverse events were observed in 8.1% (biliary peritonitis [n=3]). One-stage EUS-AI by EUS succeeded in 8 cases (100%) without any adverse events. In another 26 cases, 2-stage EUS-AI by ERCP was performed about 1 or 2 months later. Endoscopic antegrade therapy under fluoroscopy was successful in 6 cases. Per-oral cholangioscopy-assisted antegrade intervention were required in 19 cases (guidewire manipulation across the anastomotic stricture [n=6], cholangioscopy-guided lithotripsy using electrohydraulic lithotripsy [n=13]). In 1 case, magnetic compression anastomosis was performed. The final clinical success rate of all EUS-AI was 91.9%.

Conclusions: EUS-AI for benign biliary diseases with SAA appears to be a feasible and safe alternative procedure after BE-ERCP failure.



3. A systematic review and meta-analysis of metal versus plastic stents for drainage of pancreatic fluid collections: metal stents are advantageous

Saunders R et al. Surg Endosc 2018 Sep 6.[e-pub]

 Key points:

  • The advantage of lumen-apposing metal stents (LAMS) over plastic stents for the transmural drainage of pancreatic fluid collections is uncertain and recent studies have shown conflicting data;
  • European researchers conducted a database search for comparative studies and included 7 studies with 681 (340 metal, 341 plastic) patients in the meta-analysis.
  • The researchers found the use of metal stents for drainage of pancreatic fluid collections is associated with improved clinical success, fewer adverse events and reduced bleeding compared to plastic stents.


Background: The use of fully covered metal stents (FCSEMS) and specifically designed lumen apposing metal stents for transmural drainage of pancreatic fluid collections has become widespread. A systematic review published in 2015 did not support the routine use of metal stents for drainage of pancreatic fluid collections. However, recent studies have shown conflicting data; therefore a systematic review and meta-analysis was performed.

Methods: We conducted a database search for original comparative studies between plastic and metal stents. The random effects model was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). Outcomes analysed were clinical success, adverse events and requirement of further intervention.

Results: The search identified 936 studies, 7 studies with 681 (340 metal, 341 plastic) patients met inclusion criteria and were included in the meta-analysis. Clinical success was achieved in 93.8% versus 86.2% in the metal and plastic groups, respectively, RR 1.08 [95% CI 1.02-1.14]; p = 0.009. Adverse events were reduced for metal stents when compared with plastic (10.2% vs. 25.0%), RR 0.42 [95% CI 0.22-0.81]; p = 0.010. Metal stent usage reduced bleeding (2.8% vs. 7.9%), RR 0.37; [95% CI 0.18-0.75]; p = 0.006. Further intervention was required in 12.4% of patients in the metal stent group versus 26.7% for plastic stents, RR 0.54; [95% CI 0.22-1.29]; p = 0.165.

Conclusions: The use of metal stents for drainage of pancreatic fluid collections is associated with improved clinical success, fewer adverse events and reduced bleeding compared to plastic stents.



4. Tissue acquisition for diagnosis of biliary strictures using peroral cholangioscopy or endoscopic ultrasound-guided fine-needle aspiration

Lee YN et al. Endoscopy 2018 Sep 5. [e-pub] 

Key points:

  • Tissue sampling for biliary stricture is importante for differential diagnosis and further treatment.
  • ERCP with brush cytology and/or transpappilary fórceps biopsy (TPB) is the first-line procedure but its sensitivity is reported low.
  • Peroral cholangioscopy-guided forceps biopsy (POC-FB) and EUS-FNA are alternative procedures;
  • Korean researchers performed a prospective trial to evaluate the use of POC-FB and EUS-FNA in patients with suspected malignant biliary strictures.
  • POC-FB was used for proximal strictures and EUS-FNA for distal strictures.
  • 181 patients were included. Initial TPB showed a diagnostic accuracy of 71.8%.
  • In the 59 patients with negative TPB, the accuracy of POC-FB for proximal biliary strictures was 93.6% and the accuracy of EUS-FNA for distal strictures was 96.3%
  • The authors conclude that an approach using POC-FB or EUS-FNAB according to the stricture location may be useful in the diagnosis of suspected MBS.


Background: Although endoscopic retrograde cholangiopancreatography (ERCP) is a first-line diagnostic modality for suspected malignant biliary stricture (MBS), the diagnostic yield of ERCP-based tissue sampling is insufficient. Peroral cholangioscopy-guided forceps biopsy (POC-FB) and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) are evolving as reliable diagnostic procedures for inconclusive MBS. This study aimed to evaluate the usefulness of a diagnostic approach using POC-FB or EUS-FNAB according to the stricture location in patients with suspected MBS.

Methods: Consecutive patients diagnosed with suspected MBS with obstructive jaundice and/or cholangitis were enrolled prospectively. ERCP with transpapillary forceps biopsy (TPB) was performed initially. When malignancy was not confirmed by TPB, POC-FB using a SpyGlass direct visualization system or direct POC using an ultraslim endoscope was performed for proximal strictures, and EUS-FNAB was performed for distal strictures as a follow-up biopsy.

Results: Among a total of 181 patients, initial TPB showed malignancy in 122 patients, and the diagnostic accuracy of initial TPB was 71.8 % (95 % confidence interval [CI] 65.3 % - 78.4 %]. Of the 59 patients in whom TPB was negative for malignancy, 32 had proximal biliary strictures and underwent successful POC. The remaining 27 patients had distal strictures and underwent successful EUS-FNAB. The accuracy of malignancy detection using POC-FB for proximal biliary strictures and EUS-FNAB for distal biliary strictures was 93.6 % (95 %CI 84.9 %-100 %) and 96.3 % (95 %CI 89.2 %-100 %), respectively. The overall diagnostic accuracy for the combination of TPB with either POC-FB for proximal strictures and EUS-FNAB for distal strictures was 98.3 % (95 %CI 95.9 %-100 %) and 98.4 % (95 %CI 95.3 %-100 %), respectively.

Conclusions: An approach using POC-FB or EUS-FNAB according to the stricture location may be useful in the diagnosis of suspected MBS.