Moole Harsha, Bechtold Matthew L, Forcione David, Puli Srinivas R
Division of General Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL Division of Gastroenterology and Hepatology, University of Missouri-Columbia, Columbia, MO Interventional Endoscopy Services, Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA Division of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL.
Medicine (Baltimore). 2017 Jan;96(3):e5154. doi: 10.1097/MD.0000000000005154.
In patients with inoperable malignant biliary strictures, endoscopic retrograde cholangiopancreatography (ERCP) guided biliary stenting fails in 5% to 10% patients due to difficult anatomy/inability to cannulate the papilla. Recently, endoscopic ultrasound guided biliary drainage (EUS-BD) has been described.Primary outcomes were to evaluate the biliary drainage success rates with EUS and compare it to percutaneous transhepatic biliary drainage (PTBD). Secondary outcomes were to evaluate overall procedure related complications.
STUDY SELECTION CRITERIA:: Studies evaluating the efficacy of EUS-BD and comparing EUS-BD versus PTBD in inoperable malignant biliary stricture patients with a failed ERCP were included in this analysis.
Articles were searched in Medline, PubMed, and Ovid journals. Two authors independently searched and extracted data. The study design was written in accordance to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Subgroup analyses of prospective studies and EUS-BD versus PTBD were performed.
Pooled proportions were calculated using fixed and random effects model. I statistic was used to assess heterogeneity among studies.
Initial search identified 846 reference articles, of which 124 were selected and reviewed. Sixteen studies (N = 528) that met the inclusion criteria were included in this analysis. In the pooled patient population, the percentage of patients that had a successful biliary drainage with EUS was 90.91% (95% CI = 88.10-93.38). The proportion of patients that had overall procedure related complications with EUS-PD was 16.46% (95% CI = 13.20-20.01). The pooled odds ratio for successful biliary drainage in EUS-PD versus PTBD group was 3.06 (95% CI = 1.11-8.43). The risk difference for overall procedure related complications in EUS-PD versus PTBD group was -0.21 (95% CI = -0.35 to -0.06). Relative risk for infectious complications and bile leak in EUS-BD versus PTBD was 0.25 (95% CI = 0.07-0.94) and 0.33 (95% CI = 0.12-0.87), respectively.
In patients with inoperable malignant biliary strictures who failed an ERCP guided biliary stenting, EUS-BD seems to be an excellent management option and superior to PTBD with higher successful biliary drainage rates and relatively fewer complications.
在无法手术的恶性胆管狭窄患者中，由于解剖结构困难/无法插入乳头，内镜逆行胰胆管造影（ERCP）引导下的胆管支架置入术在5%至10%的患者中失败。最近，内镜超声引导下胆管引流（EUS-BD）已被报道。主要结局是评估EUS胆管引流成功率，并将其与经皮经肝胆管引流（PTBD）进行比较。次要结局是评估总体手术相关并发症。
研究选择标准：本分析纳入评估EUS-BD疗效并比较EUS-BD与PTBD在ERCP失败的无法手术的恶性胆管狭窄患者中的研究。
在Medline、PubMed和Ovid期刊中检索文章。两位作者独立检索和提取数据。研究设计按照PRISMA（系统评价和Meta分析的首选报告项目）声明编写。对前瞻性研究以及EUS-BD与PTBD进行亚组分析。
使用固定效应模型和随机效应模型计算合并比例。I统计量用于评估研究间的异质性。
初步检索确定了846篇参考文献，其中124篇被选中并进行了综述。本分析纳入了符合纳入标准的16项研究（N = 528）。在合并的患者群体中，EUS胆管引流成功的患者百分比为90.91%（95%CI = 88.10 - 93.38）。EUS-PD总体手术相关并发症的患者比例为16.46%（95%CI = 13.20 - 20.01）。EUS-PD组与PTBD组胆管引流成功的合并优势比为3.06（95%CI = 1.11 - 8.43）。EUS-PD组与PTBD组总体手术相关并发症的风险差异为-0.21（95%CI = -0.35至-0.06）。EUS-BD与PTBD相比，感染并发症和胆漏的相对风险分别为0.25（95%CI = 0.07 - 0.94）和0.33（95%CI = 0.12 - 0.87）。
在ERCP引导下胆管支架置入术失败的无法手术的恶性胆管狭窄患者中，EUS-BD似乎是一种极佳的治疗选择，优于PTBD，胆管引流成功率更高且并发症相对较少。
