Grover Dheera, Fatima Ifrah, Dharan Murali
Department of Internal Medicine, University of Connecticut, Farmington, CT 06030, United States.
Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64110, United States.
World J Gastrointest Endosc. 2023 Sep 16;15(9):574-583. doi: 10.4253/wjge.v15.i9.574.
Endoscopic ultrasound guided gallbladder drainage (EUS-GBD) is being increasingly used in practice (either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients). Stents are used to create a conduit between the lumen of the gallbladder (GB) and the intestinal lumen through the gastric or enteric routes. Among the various types of stents used, cautery-enhanced lumen apposing metallic stents (LAMS) may be associated with fewer adverse events (AEs).
To compare the clinical success, technical success, and rate of AEs between transgastric (TG) and trans-enteric [transduodenal (TD)/transjejunal (TJ)] approach to GB drainage. Further, we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters.
Study was registered in PROSPERO (CRD42022319019) and comprehensive literature review was conducted. Manuscripts were reviewed for the data collection: Rate of AEs, clinical success, and technical success. Random effects model was utilized for the analysis.
No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches ( > 0.05) were noted. There was no statistically significant difference in the rate of AEs when comparing two-arm studies only. However, when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach. When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS, a statistically significant difference in the rate of AEs was observed when all the studies were included, with the rate being higher in non-cautery enhanced stents (14.0% 37.8%; < 0.01).
As per our study results, TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD. Additionally, use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS. Though the approach chosen depends on several patient and physician factors, the above findings could help in deciding the ideal drainage route when both TG and TD/TJ approaches are feasible.
内镜超声引导下胆囊引流术（EUS-GBD）在临床实践中的应用越来越广泛（既作为高危患者胆囊切除术的过渡治疗，也作为非手术患者的最终治疗方法）。支架用于通过胃或肠道途径在胆囊腔与肠腔之间建立通道。在使用的各种类型的支架中，烧灼增强型管腔贴附金属支架（LAMS）可能与较少的不良事件（AE）相关。
比较经胃（TG）和经肠[经十二指肠（TD）/经空肠（TJ）]途径进行胆囊引流的临床成功率、技术成功率和不良事件发生率。此外，我们分析了在EUS-GBD期间使用烧灼增强型支架是否会影响上述参数。
本研究已在国际前瞻性系统评价注册库（PROSPERO，注册号：CRD42022319019）注册，并进行了全面的文献综述。对纳入的文献进行数据收集：不良事件发生率、临床成功率和技术成功率。采用随机效应模型进行分析。
TD/TJ和TG途径在临床和技术成功率方面无统计学显著差异（P>0.05）。仅比较双臂研究时，不良事件发生率无统计学显著差异。然而，当所有研究纳入分析时，差异几乎具有统计学意义，更倾向于TD/TJ途径。比较烧灼增强型LAMS与非烧灼增强型LAMS时，当纳入所有研究时，不良事件发生率存在统计学显著差异，非烧灼增强型支架的发生率更高（14.0%对37.8%；P<0.01）。
根据我们的研究结果，与TG途径相比，TD/TJ途径在EUS-GBD中似乎不良事件发生率更低，疗效相当。此外，与未增强烧灼功能的LAMS相比，在EUS-GBD中使用烧灼增强型LAMS的不良事件情况更有利。尽管选择何种途径取决于多个患者和医生因素，但上述发现有助于在TG和TD/TJ途径均可行时决定理想的引流途径。
