Open AccessCombined endoscopic mAnagement of BiliaRy and gastrIc OutLET obstruction (CABRIOLET Study): A multicenter retrospective analysis
Author(s) -
Vanella Giuseppe,
Bronswijk Michiel,
van Wanrooij Roy LJ,
Dell'Anna Giuseppe,
Laleman Wim,
van Malenstein Hannah,
Voermans Rogier P,
Fockens Paul,
Van der Merwe Schalk,
Arcidiacono Paolo Giorgio
Publication year - 2023
Publication title -
den open
Language(s) - English
Resource type - Journals
ISSN - 2692-4609
DOI - 10.1002/deo2.132
Subject(s) - medicine , interquartile range , gastric outlet obstruction , gastroenterostomy , endoscopic ultrasound , gastroenterology , stent , pancreatic cancer , context (archaeology) , retrospective cohort study , radiology , surgery , cancer , gastrectomy , paleontology , biology
Objectives Combined biliary obstruction and gastric outlet obstruction (GOO) represent a challenging clinical scenario despite developments in therapeutic endoscopic ultrasonography (EUS) as GOO might impair EUS‐guided biliary drainage. Little is known about the effectiveness of different therapeutic combinations used to treat double obstruction, especially regarding stent patency. Methods All consecutive patients with double obstruction treated between 2016 and 2021 in three tertiary academic centres were eligible for inclusion. Five combinations involving enteral stenting (ES), EUS‐guided gastroenterostomy (EUS‐GE), hepaticogastrostomy (EUS‐HGS), choledochoduodenostomy (EUS‐CDS), and transpapillary biliary stenting (TPS) were evaluated for dysfunction during follow‐up, either as proportions or dysfunction‐free survival (DFS) using Kaplan–Meier estimates. Results Ninety‐three patients were included (male 46%; age 67 [interquartile range 60–76] years; pancreatic cancer 73%, metastatic 57%), resulting in 103 procedure combinations. Different combinations showed significantly different overall dysfunction rates ( p = 0.009), ranging from the null rate of EUS‐GE+HG to the 18% rate of EUS‐GE+TPS, 31% of EUS‐GE+EUS‐CD, 53% of ES+TPS and 83% of ES+EUS‐CDS. Sub‐analyses restricted to biliary dysfunction confirmed these trends. A multivariate Cox proportional‐hazards regression of DFS, a stenosis distal to the papilla (HR 3.2 [1.5–6.9]) and ES+EUS‐CDS (HR 5.6 [2–15.7]) independently predicted dysfunction. Conclusions Despite a lack of statistical power per combination, this study introduces new associations beyond the increased risk of GOO recurrence with ES versus EUS‐GE. EUS‐CDS showed reduced effectiveness and frequent dysfunction in the context of GOO, especially when combined with ES. EUS‐GE+HGS or EUS‐GE+TPS in this setting might result in superior patency. These results suggest that a prospective evaluation of the optimal endoscopic approach to malignant double obstruction is needed.