Vanella Giuseppe, Bronswijk Michiel, van Wanrooij Roy Lj, Dell'Anna Giuseppe, Laleman Wim, van Malenstein Hannah, Voermans Rogier P, Fockens Paul, Van der Merwe Schalk, Arcidiacono Paolo Giorgio
Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre IRCCS San Raffaele Scientific Institute and University Milan Italy.
Department of Gastroenterology and Hepatology University Hospitals Gasthuisberg University of Leuven Leuven Belgium.
DEN Open. 2022 Jun 14;3(1):e132. doi: 10.1002/deo2.132. eCollection 2023 Apr.
Combined biliary obstruction and gastric outlet obstruction (GOO) represent a challenging clinical scenario despite developments in therapeutic endoscopic ultrasonography (EUS) as GOO might impair EUS-guided biliary drainage. Little is known about the effectiveness of different therapeutic combinations used to treat double obstruction, especially regarding stent patency.
All consecutive patients with double obstruction treated between 2016 and 2021 in three tertiary academic centres were eligible for inclusion. Five combinations involving enteral stenting (ES), EUS-guided gastroenterostomy (EUS-GE), hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and transpapillary biliary stenting (TPS) were evaluated for dysfunction during follow-up, either as proportions or dysfunction-free survival (DFS) using Kaplan-Meier estimates.
Ninety-three patients were included (male 46%; age 67 [interquartile range 60-76] years; pancreatic cancer 73%, metastatic 57%), resulting in 103 procedure combinations. Different combinations showed significantly different overall dysfunction rates ( = 0.009), ranging from the null rate of EUS-GE+HG to the 18% rate of EUS-GE+TPS, 31% of EUS-GE+EUS-CD, 53% of ES+TPS and 83% of ES+EUS-CDS. Sub-analyses restricted to biliary dysfunction confirmed these trends. A multivariate Cox proportional-hazards regression of DFS, a stenosis distal to the papilla (HR 3.2 [1.5-6.9]) and ES+EUS-CDS (HR 5.6 [2-15.7]) independently predicted dysfunction.
Despite a lack of statistical power per combination, this study introduces new associations beyond the increased risk of GOO recurrence with ES versus EUS-GE. EUS-CDS showed reduced effectiveness and frequent dysfunction in the context of GOO, especially when combined with ES. EUS-GE+HGS or EUS-GE+TPS in this setting might result in superior patency. These results suggest that a prospective evaluation of the optimal endoscopic approach to malignant double obstruction is needed.
尽管治疗性内镜超声检查（EUS）有所发展，但合并胆道梗阻和胃出口梗阻（GOO）仍是一个具有挑战性的临床情况，因为GOO可能会妨碍EUS引导下的胆道引流。对于用于治疗双重梗阻的不同治疗组合的有效性，尤其是关于支架通畅性，人们了解甚少。
2016年至2021年期间在三个三级学术中心接受治疗的所有连续性双重梗阻患者均符合纳入标准。对涉及肠道支架置入术（ES）、EUS引导下胃造口术（EUS-GE）、肝胃造口术（EUS-HGS）、胆总管十二指肠吻合术（EUS-CDS）和经乳头胆道支架置入术（TPS）的五种组合在随访期间的功能障碍情况进行评估，采用Kaplan-Meier估计法以比例或无功能障碍生存期（DFS）来表示。
纳入93例患者（男性占46%；年龄67岁[四分位间距60 - 76岁]；胰腺癌占73%，转移性占57%），共进行了103次手术组合。不同组合的总体功能障碍率差异显著（P = 0.009），范围从EUS-GE+HGS的零发生率到EUS-GE+TPS的18%、EUS-GE+EUS-CDS的31%、ES+TPS的53%以及ES+EUS-CDS的83%。限于胆道功能障碍的亚分析证实了这些趋势。DFS的多变量Cox比例风险回归分析显示，乳头远端狭窄（风险比[HR] 3.2 [1.5 - 6.9]）和ES+EUS-CDS（HR 5.6 [2 - 15.7]）可独立预测功能障碍。
尽管每种组合的统计学效力不足，但本研究揭示了除ES与EUS-GE相比GOO复发风险增加之外的新关联。在GOO背景下，EUS-CDS显示出有效性降低且功能障碍频繁，尤其是与ES联合使用时。在此情况下，EUS-GE+HGS或EUS-GE+TPS可能会有更好的通畅性。这些结果表明需要对恶性双重梗阻的最佳内镜治疗方法进行前瞻性评估。
