Stent Selection in EUS-Guided Hepaticogastrostomy for Malignant Biliary Obstruction: A Multicenter Retrospective Study

Aims Biliary drainage through EUS-guided hepaticogastrostomy has proven effective in patients with malignant biliary obstruction (MBO) when ERCP is unsuccessful or unfeasible. The technique is still under standardization, and there is no consensus on the type of stent to use. Traditionally, partially covered self-expanding metal stents (PC-SEMS) have been preferred due to lower migration rates. However, occlusion rates due to ingrowth as high as 27% have been reported. Fully covered SEMS (FC-SEMS) with anti-migration flaps may address stent occlusion while minimizing migration risks.

Methods This multicenter retrospective study analyzed EUS-guided hepaticogastrostomies performed between 2017 and 2024 in three tertiary centers as palliative drainage for patients with MBO unsuitable for ERCP. Demographic, procedural, and follow-up data were collected. The primary outcome was the rate of biliary reobstruction (RBO), defined as jaundice or biliary infection due to sludge or ingrowth, and the need for biliary reintervention (BRI). Statistical analysis included uni/multivariate and survival analysis comparing FC-SEMS and PC-SEMS [1] [2] [3].

Results Data were obtained for 162 patients (52.8% male, mean age 71.13±20.51 years). The most frequent cause of MBO was pancreatic cancer (60.93%), followed by distal cholangiocarcinoma (15.89%). The primary reasons for hepaticogastrostomy were duodenal infiltration (40.44%) and postsurgical anatomy (22.79%). Baseline variables showed no significant differences between patients receiving FC-SEMS and PC-SEMS (50.93% vs. 49.07%, respectively). The clinical success rate was 83.75%, with an adverse event rate of 19.25%, most of which were mild to moderate (AGREE II: 43.75%). Overall, the RBO rate was 16.15% during a mean follow-up of 79 days (IQR 31–195)***. Among patients with RBO, 69.57% required intervention, achieving a clinical success rate of 87.4%. In comparative analysis, no significant differences in RBO rates were found between FC-SEMS and PC-SEMS after adjusting for technical variables (dilation, anchoring with pigtails, etc.). Survival analysis also revealed no differences in stent patency (p=0.1).

Conclusions EUS-guided hepaticogastrostomy with SEMS is a safe medium-term biliary drainage method, achieving stent patency above 80% with effective resolution of obstructions. The choice between FC-SEMS and PC-SEMS does not significantly impact stent patency, suggesting that selection should rely on the endoscopist’s expertise and available resources.

 

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Conflicts of Interest

Authors do not have any conflict of interest to disclose.

• References

• 1 De Cassan C, Bories E, Pesenti C. et al. Use of partially covered and uncovered metallic prosthesis for endoscopic ultrasound-guided hepaticogastrostomy: Results of a retrospective monocentric study. Endosc Ultrasound 2017; 6: 329-35
• 2 Guo J, Giovannini M, Sahai AV, Saftoiu A, Dietrich CF, Santo E. et al. A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction. Endosc Ultrasound 2018; 7: 356-65
• 3 Rai P, Lokesh CR, Goel A. et al. Endoscopic ultrasound-guided choledochoduodenostomy using partially-covered self-expandable metal stent in patients with malignant distal biliary obstruction and unsuccessful ERCP. Endosc Int Open 2018; 6: E67-72

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025