Efficacy and safety of Endoscopic ultrasound-guided hepaticogastrostomy for biliary obstruction: A comprehensive systematic review, meta-analysis and meta-regression

Aims Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative method of biliary drainage in patients presenting with biliary obstruction (BO). This meta-analysis with meta-regression comprehensively aimed to study success, efficacy and safety of EUS-HGS.

Methods Several databases were systematically searched for studies evaluating EUS-HGS for BO till April 2023. Studies with<10 patients were excluded. Primary outcome was the technical and clinical success of procedure. Secondary outcomes included adverse events (AE), survival time, reintervention, recurrent biliary obstruction and stent patency rates. Sub-group analysis based on type of stent, year of publication as well as geographical differences (east vs west) were also conducted.

Results Sixty-eight studies (18 prospective) with 3292 patients (59.8% males) were included. Most common indication was malignant BO (93.1% patients). Pooled rates of technical and clinical success were 97.1% (93.4%-100%, I²=0; 68 studies) and 84.0% (95% CI 79.0-88.1%, I²=14.7%, 57 studies) respectively. Mean procedure time was 28.9 minutes (95% CI 22.0-35.8%, I²=73.1%; 24 studies). Adverse events were noted in 26.1% (95% CI 21.8-30.4%, I²=29.9%; 68 studies) patients with majority being mild 10.0% (95% CI 4.3-15.6%, I²=0%; 20 studies). Pooled rates of moderate and serious AE were 9% (95% CI 3%-14%, I²=0%; 21 studies) and 2.8% (95% CI 3.6-9.1%, I²=0%, 10 studies), respectively. Various AE included pain (7%), perforation (2%), bile leak (3%), peritonitis (7%), bleeding (3%) and sepsis (6%).

Pooled rates of stent patency were 93.78 days (95% CI 78-109.2; I²=0%; 13 studies). Pooled rates of recurrent biliary obstruction (RBO) were 22% (95% CI 16%-27%; I²=0%; 25 studies). Pooled reintervention rates were 19.0% (95% CI 14.7-23.3%, I²=0%, 44 studies) patients. Overall survival was 101.6 days (95% CI 60.9-142.4%, I²=0%, 9 studies) and death was observed in 3.5% (95% CI 3.1-10.0%, I²=0%, 13 studies) patients. On meta-regression, year of publication was associated with decreasing rates of AE (32% vs 23%; p=0.04). Clinical success rates were higher in studies reported from the east (compared to the west), but did not differ amongst types of stents (metal vs. plastic) or type of publication (prospective vs retrospective).

Conclusions As a modality for biliary drainage, EUS-HGS has high rates of technical and clinical success with low rates of serious adverse events. Data suggests that rates of adverse events have declined with time, probably due to improved operator experience and technique.

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Artikel online veröffentlicht:
15. April 2024