Role of Endoscopy in Malignant Biliary Obstruction.pptx

Role of Endoscopy in Malignant Biliary Obstruction

1. ROLE OF ENDOSCOPY IN MALIGNANT BILIARY OBSTRUCTION Dr Chetan Saner

2. Causes of MBO: Pancreatic Carcinoma Cholangiocarcinoma Ca GB Periampullary Carcinoma Metastasis

3. Endoscopy: Diagnostic or Therapeutic Diagnostic: tissue sampling ERCP - EUS – EUS FNB Bile Aspiration Cytology Brush Cytology Intraductal Biopsies Cholangioscopic Imaging and Biopsy FISH DIA

4. Bile Aspiration Cytology: 20% Sensitivity Brush Cytology: S tandard brush - 1.5 cm long, bristles oriented at 90°, 6F sheath Modified Brush - 3 mm in diameter, 5 cm long, bristles are oriented at 45°,7F sheath Sensitivity – 30% Zoundjiekpon VD, Falt P, Zapletalova J, Vanek P, Kurfurstova D, Slobodova Z, Skanderova D, Korinkova G, Skalicky P, Lovecek M, Urban O. Fluorescence In Situ Hybridization in Primary Diagnosis of Biliary Strictures: A Single- Center Prospective Interventional Study. Biomedicines. 2023 Mar 2;11(3):755.

5. Intraductal Biopsies: Wire guided forceps ( Histoguide ) placed trans-papillary and Biopsies taken for HPE Sensitivity – 40 - 50% All 3 Combined – 60% Cholangioscopic Biopsy: Sensitivity – 90% Cholangioscopic Imaging Characteristics: Tumor Vessels, Papillary Projection, Nodular Or Polypoid Mass, And Infiltrative Lesions Angsuwatcharakon P, Kulpatcharapong S, Moon JH, Ramchandani M, Lau J, Isayama H, Seo DW, Maydeo A, Wang HP, Nakai Y, Ratanachu -Ek T. Consensus guidelines on the role of cholangioscopy to diagnose indeterminate biliary stricture. Hpb . 2022 Jan 1;24(1):17-29.

6. Shin IS, Moon JH, Lee YN, Kim HK, Chung JC, Lee TH, Yang JK, Cha SW, Cho YD, Park SH. Detection and endoscopic classification of intraductal neoplasms of the bile duct by peroral cholangioscopy with narrow-band imaging (with videos). Gastrointestinal Endoscopy. 2023 May 1;97(5):898-910.

7. FISH: Enables detection of aneuploidy for chromosomes 3, 7, and 17 and loss of the 9p21 Sensitivity – 60% (all 4 combined increases to 71-84%) Digital Imaging Analysis (DIA) : D etects early chromosomal aberrations in the malignant cells   EUS FNB: Sensitivity around 80% and Specificity around 94%

8. Therapeutic Role of Endoscopy: Endoscopic Retrograde Cholagiopancreaticography (ERCP): Gold standard for MBO for providing symptomatic relief and biliary decompression Procedure success rate is more than 90% ERCP gives Bismuth Corlette staging for Hilar CCA and helps in pre-operative planning Canakis  A, Baron TH. Relief of biliary obstruction: choosing between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. BMJ Open Gastro 2020;7:e000428. doi:10.1136/ bmjgast-2020-000428 ERCP –third edition – T.H.Barron -2019

9. Several studies of ERCP biliary drainage with SEMS showed stent patency duration of more than 240-583 days and adverse event rates of 5% to 8%, with severe AE 0.1-1% Canakis A, Kahaleh M. Endoscopic palliation of malignant biliary obstruction. World J GIE. 2022

10. NEWER APPLICATIONS IN ERCP ENDO-BILIARY ABLATIVE THERAPY: 1. Photodynamic Therapy: Survival and stent patency benefit in three meta-analysis A synergistic effect between PDT and systemic chemotherapy has also been confirmed Light waves can refract to the proximal biliary tree that is beyond the reach of the guidewire Moole H, Duvvuri A. et al :Success of photodynamic therapy in palliating patients with nonresectable cholangiocarcinoma: A systematic review and metaanalysis . World J Gastroenterol 2017 Gonzalez-Carmona MA, Bolch M, Weismüller TJ. Combined photodynamic therapy with systemic chemotherapy for unresectable cholangiocarcinoma. Aliment Pharmacol Ther 2019; 49: Canakis A, Kahaleh M. Endoscopic palliation of malignant biliary obstruction. World J Gastrointest Endosc 2022; 14(10): 581-596

11. Moole H, Tathireddy H, Dharmapuri S, Moole V, Boddireddy R, Yedama P, Dharmapuri S, Uppu A, Bondalapati N, Duvvuri A. Success of photodynamic therapy in palliating patients with nonresectable cholangiocarcinoma: A systematic review and meta-analysis.  World J Gastroenterol  2017; 23(7): 1278-1288 [PMID: 28275308 DOI: 10.3748/wjg.v23.i7.1278 ]

12. 2. Radio Frequency Ablation: A 2024 meta-analysis of six RCTs of 481 patients demonstrated improved survival benefit of 85 days and stent patency benefit of 22 days. De Oliveira Veras M, Et al Intraductal radiofrequency ablation plus biliary stent versus stent alone for malignant biliary obstruction: a systematic review and meta-analysis. Endosc Int Open. 2024 Mar

13. 3. Drug Eluding Stents Meta- analysis comparing Paclitaxel DES vs SEMS Mohan BP, Canakis A, Khan SR, Chandan S, Ponnada S, McDonough S, Adler DG. Drug Eluting Versus Covered Metal Stents in Malignant Biliary Strictures—Is There A Clinical Benefit?: A Systematic Review and Meta-Analysis. Journal of Clinical Gastroenterology. 2021 Mar 1;55(3):271-7. overall survival stent patency DES 168.3 149.4 SEMS 267.2 218.2 

14. Endoscopic Ultrasound EUS BD has evolved into reliable alternative to PTBD where ERCP fails EUS BD vs PTBD – comparable clinical and technical success, lower rates of reintervention and fewer post procedure adverse events Re-intervention rate is less in EUS BD Baniya R, Upadhaya S, Madala S, et al . Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage after failed endoscopic retrograde cholangiopancreatography: a meta-analysis. Clin Exp Gastroenterol 2017;10:67–74 7 Sharaiha RZ, Khan MA, Kamal F, et al . Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta- analysis. Gastrointest Endosc 2017;85:904–14 Lee TH, Choi J-H, Park DH, et al . Similar efficacies of endoscopic ultrasound-guided transmural and percutaneous drainage for malignant distal biliary obstruction. Clin Gastroenterol Hepatol 2016;14:1011–9

15. EUS-BD 3 Approaches : Rendezvous Antegrade Transluminal - Intrahepatic Or Extrahepatic

16. Endoscopic Ultrasound-Guided Rendezvous ERCP EUS-RV is typically reserved as salvage therapy after failed ERCP with biliary access in patients with intact gastroduodenal anatomy Transgastric or Transduodenal L imited success rate - 80%, AEs Rate - 11.6% (bleeding, bile leakage, peritonitis, pneumoperitoneum and pancreatitis) Okuno N, Hara K, Mizuno N, et al . Endoscopic ultrasound-guided rendezvous technique after failed endoscopic retrograde cholangiopancreatography: which approach route is the best? Intern Med 2017;56:3135–43

17. Antegrade Drainage T ransgastric puncture into the left intrahepatic biliary system with passage of a guidewire into the duodenum Limited Data Technical Success – 77% , AEs - 5% ( hepatic haematoma and pancreatitis) C omplicated and cumbersome nature of guidewire placement and risk peritoneal bile leakage at the site of puncture Nguyen-Tang T, Binmoeller K, Sanchez- Yague A, et al . Endoscopic ultrasound (EUS)-guided transhepatic anterograde self-expandable metal stent (SEMS) placement across malignant biliary obstruction. Endoscopy 2010;42:232–6.

18. Transmural Drainage Hepaticogastrostomy (HGS) C reation of a fistula from the gastric cardia or lesser curvature of the stomach to a left intrahepatic duct Choledochoduodenostomy (CDS) F istula between the duodenum and extrahepatic bile duct

19. Canakis A, Baron TH. Relief of biliary obstruction: choosing between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. BMJ Open Gastro 2020

20. Meta analysis by Uemura et al of 10 studies with 434 patients had adverse event rates of 18.5% with EUS CDS and 19.2% with EUS HGS Uemura RS, Khan MA, et al : EUS-guided CDS Versus HGS : A Systematic Review and Meta-analysis. J Clin Gastroenterol 2018

21. Meta analysis of 17 studies of 686 patients had adverse event rates of 29% for EUS HGS and 20 % for EUS CDS Hedjoudje A, Sportes A, et al. Outcomes of endoscopic ultrasound-guided biliary drainage: a systematic review and meta analysis. United European Gastroenterol J. 2019

22. Meta analysis of several studies of EUS choledocoduodenostomy and hepaticogastrostomy have shown adverse event rates ranging between 20% and 46% Recurrent biliary obstruction between (26% - 33%) S econdary to stent migration (18%) S ludge/food impaction (9%) Duodenal wall impaction (3%) Canakis A, Kahaleh M. Endoscopic palliation of malignant biliary obstruction. World J GIE. 2022

23. PROBLEMS WITH EUS HGS Mediastinitis
Stent landing in the lower esophagus
Risk of migration due to peristalsis of the stomach and liver movement during respiration Segmental cholangitis or liver abscess secondary to obstruction of peripheral bile ducts Contraindicated in gastric wall tumor infiltration and gross ascites EUS HGS – Pre-requisite -A bile duct diameter > 5 mm and hepatic portion length ⩽ 3 cm

24. Type of Stent I nfluences clinical, technical and AE rates Plastic vs SEMS AEs - Plastic vs SEMS ( 31% vs 17%) SEMS vs LAMS EC-LAMS - demonstrated favourable technical (93.8%) and clinical (95.9%) success with a 5.6% AEs rate (subgroup meta-analysis of five studies involving 201 subjects) Wang K, Zhu J, Xing L, et al . Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review. Gastrointest Endosc 2016;83:1218–27 Krishnamoorthi R, Dasari CS, Thoguluva Chandrasekar V, et al . Effectiveness and safety of EUS-guided choledochoduodenostomy using lumen-apposing metal stents (LAMS): a systematic review and meta-analysis. Surg Endosc 2020;34:2866–77

25. Steep learning curve A multicentric study showed technical success < 70% in first 20 procedure and high adverse event rates of 53% in the first 3 years which then declined to 22% in the last year of the study Study by Tyberg et al. concluded that approximately 100 procedures are needed to master EUS-BD

26. >90% 4%-8% 0.1%-1% 12-42 min Rs. 45k for SEMS (BS) 240-583 days Endobiliary Ablative therapy EUS ERCP <70% initially 21%-53% upto 10% 59 min Rs. 1.3 L for Axios LAMS(BS) 155-379 days - Technical & Clinical Success Adverse Events Severe Adverse Events Median Procedure Time Cost Stent Patency Rate Survival benefit , Increased stent patency Endosonography - BY Shyam Varadarajulu, Paul Fockens,Robert H. Hawes.2023

27. ERCP is feasible but EUS BD is not! Ascites Liver metastasis Need to drain specifically Rt lobe of liver Left lobe atrophy, gastric wall infiltration Intrahepatic BD not fully dilated Newer Paclitaxel DES EUS Bile leak, Perforation Stent misdeployment in peritoneal cavity Recurrent biliary obstruction (26-33%) Stent migration Sludge/food impaction Segmental cholangitis, Liver abscess, Mediastinitis, Stent landing in lower esophagus Canakis A, Baron TH. Relief of biliary obstruction: choosing between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. BMJ Open Gastro 2020

28. EUS GB drainage : Requires many pre-requisites: Gallbladder should be adequately distended
Cystic duct patency and lack of malignant involvement of the cystic duct orifice should be established
Close apposition between the gallbladder wall and the gastrointestinal tract
The level of biliary obstruction should be distal to the cystic duct origin. Kalva et al. in their meta-analysis found overall adverse event rate of 18- 25 %. Issa D, Irani S, et al Endoscopic ultrasound-guided gallbladder drainage as a rescue therapy for unresectable malignant biliary obstruction: a multicenter experience. Endoscopy 2020 Sobani ZA, Ling C, Rustagi T. Endoscopic Ultrasound-Guided Gallbladder Drainage. Dig Dis Sci 202

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