Adherence to the ESGE Guidelines on biliary stenting in malignant distal strictures: results from a prospective cohort study (PROTESIED) in Italy

Aims Distal Malignant Biliary Strictures (dMBS) are a common indication for endoscopic retrograde cholangiopancreatography (ERCP). In 2017 ESGE published guidelines on endoscopic biliary stenting, with a chapter focusing on endoscopic stenting in dMBS. The aim of this study is to evaluate the adherence of Italian endoscopic centers to the ESGE guidelines on dMBS stenting.

Methods This is a prospective cohort observational, multicenter, study promoted from the Italian Society of Digestive Endoscopy (SIED). All consecutive patients with dMBS were included in the registry, as part of the normal care pathway. Clinical and technical data were recorded. A clinical follow-up at 7, 30 days, and then every 3 months was obtained to verify the occurrence of cholangitis, the need for re-interventions, and the oncological evolution. Follow-up had a maximum period of 1 year and was stopped at the time of the first episode of cholangitis, upon surgery or death. The adherence to the 8 ESGE recommendation was defined as “full-”, “intermediate-”, and “poor-” (>85%,≥65% –≤85%, and<65%) according to the guidelines, respectively.

Results Seventeen Italian endoscopy centers adhered to the study. Between January 2020 and January 2022, 827 patients were included (51.7% male, median age 71 years). Pancreatic head cancer was the most common etiology (79.3%). ERCP was successfull in 97% of cases. Self-Expandable Metal Stent (SEMS) was the most common biliary stent used (77.6%) (Fully Covered 63.1%; Partially Covered 9.6%; Uncovered 27.3%). The indications for ERCP were palliation, neoadjuvant chemotherapy, and preoperative drainage in 55.8%, 23%, and 21.2% of cases, respectively. Full-adherence to the guidelines was reported for post-ERCP acute pancreatitis prophylaxis (94.1% received 100 mg rectal indomethacin), for retreatments (75 patients had a second ERCP for stent dysfunction: 86.6% received a new SEMS or a plastic stent within the SEMS), and for preoperative biliary drainage indication (12% of asymptomatic jaundice patients underwent surgery within 7 days from ERCP). Intermediate-adherence to guidelines was reported for the type of stent used in palliative drainage (85% received SEMS and 15% plastic stents). Poor-adherence to guidelines was reported for the type of stent used in preoperative drainage (42% plastic stents), for the availability of pathological diagnosis in case of U-SEMS placement (45% of U-SEMS were placed without a pathological confirmed diagnosis), for the antibiotic prophylaxis (70.6%, while guidelines recommend against routine antibiotic prophylaxis), and for sphincterotomy performance (performed in 87.9%, while guidelines recommend against routine sphincterotomy). [1]

Conclusions The adherence to ESGE guidelines needs to be improved in specific topics, such as the excessive use of plastic stents, the routine performance of sphincterotomy and the use of U-SEMS without pathological diagnosis.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Dumonceau JM, Tringali A, Papanikolaou IS. et al. Endoscopic biliary stenting: Indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline – Updated October 2017. Endoscopy. Published online 2018

Publikationsverlauf

Artikel online veröffentlicht:
15. April 2024