GIE Associate Editor Amy Tyberg, MD, FASGE, highlights this article from the July issue: “EUS-guided hepaticogastrostomy versus EUS-guided hepaticogastrostomy with antegrade stent placement in patients with unresectable malignant distal biliary obstruction: a propensity score–matched case-control study” by Hirotoshi Ishiwatari, MD, PhD, et al.

The advanced endoscopist plays a key role in the palliation of patients with unresectable pancreatic cancer. For such patients, quality of life is paramount. Biliary decompression is an important palliative intervention traditionally accomplished via transpapillary ERCP.

In patients where conventional transpapillary ERCP is infeasible, EUS-guided biliary drainage (EUS-BD) has become an efficacious and safe alternative and, in some studies, has shown a preferable safety profile to conventional ERCP. EUS-BD can be performed by placement of a hepaticogastrostomy, choledochoduodenostomy, or antegrade transpapillary stent. Regardless of the technique, stent occlusion requiring repeat endoscopic intervention can occur over time, negatively impacting quality of life for these patients. 

In this study, Ishiwatari et al retrospectively evaluated performing EUS-BD with hepaticogastrostomy to EUS-BD with hepaticogastrostomy and antegrade stent placement (HGAS) in the same session using matched cohorts. They showed that HGAS significantly extended time to stent occlusion, decreasing the number of interventions and assumedly positively impacting quality of life.

Importantly, no increase in adverse events was seen in the HGAS group despite the increased complexity of the procedure in placing 2 stents, with actually a trend toward less severe postprocedural peritonitis, hypothesized because of drainage of bile through the antegrade stent prior to placement of the hepaticogastrostomy stent.  

As oncologic therapies improve and survival lengthens for patients with unresectable pancreatic cancer, minimally invasive procedures that maximize intervention-free longevity will become increasingly important in championing patients’ quality of life.

EUS-guided hepaticogastrostomy with antegrade stent placement. A, After confirming the biliary obstruction by cholangiogram, a metal stent was placed using an antegrade stent placement technique. B, After antegrade stent placement, a metal stent was deployed between the intrahepatic bile duct and stomach (hepaticogastrostomy).

Read the full article online.

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