Malignant Biliary Obstruction
Conditions
Brief summary
Endoscopic retrograde cholangiopancreatography (ERCP) stands as the primary approach for addressing jaundice in individuals with distal malignant biliary obstruction. A premise element in achieving success during therapeutic ERCP is selective biliary cannulation (SBC). Nevertheless, SBC doesn't consistently yield favorable outcomes, even among expert endoscopists, failing in around 25% to 50% of cases with standard ERCP approach (sphincterotome and guidewire). In such situations, depending on the endoscopist's experience and preference, various advanced techniques come into play. These encompass the double guidewire cannulation approach, needle-knife precut papillotomy or fistulotomy, and transpancreatic sphincterotomy, serving as potential rescue methods. In recent times, the EUS-guided approach has been gaining increasing significance. Initially, it was viewed as a rescue option in cases where advanced ERCP techniques failed (5-15% of cases). More recently, it has proved its feasibility as a first line alternative to ERCP in scenarios involving malignant biliary obstruction.
Detailed description
Rationale of the study Patients with distal malignant biliary obstruction have a higher risk of ERCP failure, related to the difficulty of bile duct cannulation. These patients after standard ERCP strategies failure, undergo advanced ERCP rescue strategies and in case of failure to EUS guided biliary drainage. HoweverEUS guided biliary drainage performed following the attempted advanced ERCP strategies, it may carry the risk of adverse events of advance ERCP strategies. We hypothesize that, in this setting of patients, early EUS guided biliary drainage in case of difficult biliary cannulation has a lower risk of post-procedural adverse events, as well as better overall safety and efficacy profiles. This could imply better outcomes such as for those patients who are planned to receive a chemotherapy before surgery in which a complication, such as acute pancreatitis, could delay the treatment.
Interventions
PROCEDUREpre-cut biliary sphincterotomy/fistulotomy, double guide wire (DGW) technique
Rescue techniques, such as pre-cut biliary sphincterotomy/fistulotomy, double guide wire (DGW) technique, wire-guided cannulation over a pancreatic stent and transpancreatic biliary sphincterotomy, will be used at the discretion of the endoscopist \[12\]. After deep cannulation, a cholangiogram to better define the characteristics of the stenosis will be done. The stent will then be inserted over a guidewire and deployed across the stenosis. All stents will be fully covered SEMSs or partially covered SEMSs of 10 mm diameter. The length of the stent will be chosen at the discretion of the endoscopist performing the procedure. A prophylactic pancreatic stent will be placed in patients who will be thought to be at high risk of post-procedure pancreatitis at the discretion of the treating endoscopist.
Sponsors
Istituto Clinico Humanitas
Study design
Allocation
RANDOMIZED
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age ≥18 years * Patients with distal malignant biliary obstruction * Abdominal ultrasound or computed tomography or magnetic resonance or EUS showing a dilated common bile duct \> 15 mm diameter. * Difficult biliary cannulation defined as ESGE guidelines * Agree to receive follow up phone calls * Able to provide written informed consent
Exclusion criteria
* Coagulation and/or platelets hereditary disorders and/or INR\>1.5, PLT\<50,000 103/mm3. * Use of anticoagulants that cannot be discontinued * Pregnant women * Previous ERCP or EUS-BD attempt * Inability to sign the informed consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Rate of AE | 0 to 3 months | such as the occurrence of unintentional perforation, bleeding requiring hemostasis, pancreatitis, stent malposition or migration, cholecystitis or cholangitis, jaundice, peritonitis, symptomatic bile leak, subcapsular liver hematoma, pneumoperitoneum, retained sheared wire, and procedure-related death |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Rate of technical success | 0 to 3 months | Defined as the rate of successful stent placement in the desired duct at the initial procedure) |
| Rate of clinical success | 0 to 3 months | Defined as decrease of bilirubin level to either half the initial level, or less than 3 dl/mg -in order to allow to start chemotherapy |
| Rate of any of the specific adverse events | 0 to 3 months | such as the occurrence of unintentional perforation, bleeding requiring hemostasis, pancreatitis, stent malposition or migration, cholecystitis or cholangitis, jaundice, peritonitis, symptomatic bile leak, subcapsular liver hematoma, pneumoperitoneum, retained sheared wire, and procedure-related death |
| Rate of reintervention | 0-3 months | in the 3 months following the procedure, will evaluate the patients who need a reintervention |
| Rate of cross-over | 0-3 months | Defined as in case of failure of the procedure established by the randomization the rate of crossover to the other procedure done. |
| Time needed for technical success | during procedure | duration of a successful procedure |
Contacts
Primary ContactAlessandro Repici, Prof.,MD
Backup ContactMarco Spadaccini, PhD,MD
Outcome results
None listed