IS USEFUL A COAXIAL PLASTIC STENT WITHIN A LUMEN-APPOSING METAL STENT FOR THE PALLIATIVE MANAGEMENT OF MALIGNANT BILIARY OBSTRUCTION?

Aims There are doubts concerning the possible benefits derived from the insertion of double-pigtail plastic stents (DPPS) within the lumen-apposing metal stents (LAMS) in the EUS-guided transmural biliary drainage (BD). Aims to assess if the use of a coaxial DPPS within a LAMS provides more security in the EUS-BD for the palliative management in malignant biliary obstruction.

Methods This is a multicenter retrospective study from 3 tertiary institutions. Period: May 2015 to October 2019. Comparative evaluation of two strategies: biliary LAMS with vs without DPPS.

Inclusion Unresectable/inoperable biliopancreatic cases, with failed CPRE. Exclusion: borderline cancer cases, use of others stents.

Clinical success Bilirubin decrease > 50% at 4 weeks.

Results Twenty-eight cases of EUS-BD (cholechoduodenostomies) using LAMS. Eighteen women (64%), mean age 70,4 years. Indication: jaundice (n=23), cholangitis (n=5). CBD diameter: average 17.3 mm (SD 3.71mm). Technical success: 100%. Freehand technique + guidewire (n=12), previous puncture with needle 19 G + guidewire (n=16). Technical and clinical success rates of 100% and 82%, respectively. Major proportion of LAMS alone (61%) compared to LAMS + coaxial DPPS (39%). Global adverse events (AE) of 17.8%, and for each group (LAMS, 18% of AEs; LAMS+DPPS 17,6% of AEs). Immediate AE (< 24h): duodenal perforation (n=1), bleeding (n=1), migration (n=1). Late AEs: peritonitis (n=1), cholecystitis (n=1). Three late cholangitis (10.7%) that required reintervention for occluded stent. No differences in safety related to different technical aspects (freehand vs needle). No differences between both groups, in terms of clinical success, survival and safety. Minor length of procedure without DPPS placement (91.3 min vs. 46.2 min p < 0.05).

Conclusions The technical variant of adding a coaxial DPPS within LAMS in EUS-BD procedures of malignant biliary obstruction, does not seem to increase the safety and lengthens the procedure time.