EUS-Guided Biliary Drainage (EUS-BD) With Lumen Apposing Metal Stent (LAMS) For Unresectable Malignant Biliary Obstruction (MBO) After Ercp Failure: Single-Center Real-Life Retrospective-Study With Maldeployment Management

Aims EUS-BD with LAMS is a mini-invasive modality treatment for jaundice palliation in distal MBO not amenable to ERCP, with good efficacy and not insignificant reported Adverse Events (AEs) rate.

Methods From January 2015 to December 2019, we retrospectively enrolled all the EUS-BDs with electrocautery-enhanced-LAMS (AXIOS-EC™, Boston Scientific) for biliary decompression in unresectable MBO and failed ERCP. Our primary study aims were to evaluate the technical\clinical success and AEs rate. In case of maldeployment, we estimate the efficacy of an intra-operative Rescue Therapy (RT). Secondary aims were jaundice’s recurrence and Gastric Outlet Obstruction (GOO) treatment with uncovered Self-Expandable-Metal-Stent (u-SEMS – Wallflex, Boston Scientific).

Results Thirty-six EUS-BDs were enrolled over a cohort of 738 patients (ERCP cannulation failure rate: 2.8 %): 31 choledocho-duodenostomy (EUS-CDS) and 5 cholecisto-gastrostomy. A pre-loaded guidewire was systematically inserted in case of common bile duct (CBD) ≤15mm or scope instability for a safe\preventive biliary entryway. Mean CBD diameter: 16,03±3,59 mm. Technical success was 80.6 % with 7 cases of maldeployment during EUS-CDS with LAMS’s first flange release outside the CBD wall into the abdominal cavity, successfully (100 % efficacy) treated with a Fully-Covered-SEMS (FC-SEMS).

Tab. 1

Overall LAMS size (n/%):	6x8 mm (1/2,8 %); 8x8 mm (24/66,7 %); 10x10 mm (9/25 %); 15x10 mm (2/5,6 %).
Use of guidewire:	10 cases (8 with CBD diameter ≤ 15mm and 2 CBD diameter >15mm for scope instability and unexpected LAMS delivery catheter malfunction).
CBD diameter and LAMS size in maldeployment:	≤15mm and 8x8mm Axios-stent in 6 cases and 24mm and 10x10mm Axios-stent in 1 case.
Rescue therapy for maldeployment (60x10 mm or 80x10 mm FC-SEMS placement after complete LAMS removal):	Over-the-wire endoscopic deployment through the novel fistula tract (5/7). Transpapillary percutaneous-transhepatic-endoscopic rendezvous* (1/7) and transpapillary laparoscopic-endoscopic rendezvous* (1/7) *due to the immediate decompression of the biliary system after the puncture with loss of CBD wall’s tone and so a not clear\valid utrasonographic window.
Overall pre-operative and after 2-weeks bilirubin levels:	13,39±4,8 mg\dl vs 2,75±3,04 mg\dl

Same-session duodenal u-SEMS placement was executed in 16/36 patients with optimal GOO management. Definitive clinical success was 100 %. Other AEs weren’t observed.

Conclusions EUS-BD with LAMS is effective for jaundice palliation in unresectable MBO after “high-quality” ERCP failure. Our technical success was undermined by intra-procedural maldeployment that remains a serious complication with fatal evolution if not correctly recognized\managed. RT, using variable accessories and devices from different interventional specialties, must be promptly applied especially in tertiary-care centers where endoscopists must be high-skilled in EUS\ERCP\stenting. Complete pre-operative evaluation with minimum echoendoscope angulation, smaller-fit-size LAMS and pre-loaded guidewire are key points when a salvage EUS-BD is required in condition of CBD≤15mm, unlike LAMS delivery catheter malfunction or scope instability.

Citation Di Mitri R, Amata M, Mocciaro F et al. eP426 EUS-GUIDED BILIARY DRAINAGE (EUS-BD) WITH LUMEN APPOSING METAL STENT (LAMS) FOR UNRESECTABLE MALIGNANT BILIARY OBSTRUCTION (MBO) AFTER ERCP FAILURE: SINGLE-CENTER REAL-LIFE RETROSPECTIVE-STUDY WITH MALDEPLOYMENT MANAGEMENT. Endoscopy 2021; 53: S235.

Publication History

Article published online:
19 March 2021