EUS guided Hepaticogastrostomy versus ERCP and SEMS placement within SEMS as reintervention in patients with blocked biliary metal endoprosthesis

Aims With improved survival in patients with pancreaticobiliary malignancies, patients presenting with blockage of existing biliary metal endoprosthesis is often encountered. EUS-HGS as reintervention may presumably lead to better stent opening due to separate fistulous tract with better drainage and lower need for reintervention as compared to ERCP and self-expanding metal stent (SEMS) placement within existing SEMS. The aim was to compare SWS with EUS-HGS as reintervention after blocked biliary metal endoprosthesis.

Methods Retrospective review of endoscopy database for patients who underwent either SWS or EUS-HGS for blocked previously placed SEMS between January 2021 and June 2024. The choice of intervention was based on endoscopist’s discretion. Patients with previous history of reintervention for blocked biliary SEMS and those with complex hilar blocks with multi-segmental drainage were excluded. Primary outcome was need for re-intervention after SWS or EUS-HGS. Secondary outcomes were immediate clinical success of drainage (decrease in bilirubin to<50% of pretreatment value in 2 weeks or normalization in 4 weeks with resolution of cholangitis), reintervention free survival and overall survival.

Results Sixty-one patients were included in the analysis (39 SWS, 22 EUS-HGS; Mean age 54.66+12.08 years, 55.7% Males). Cholangitis was seen in 59% (36/61) at presentation. Median days since primary SEMS placement was 187 days. No difference was seen in the two groups in terms of age, sex, cholangitis, baseline bilirubin, days since primary intervention or ascites. Technical success of SWS and EUS-HGS was 100%. No major complications were seen in both cohorts. Functional success was achieved in 92.3% in SWS group and 100% in EUS-HGS group (p=0.547). Reintervention was needed after SWS in 6 (15.4%) patients and after EUS-HGS in 1 (4.5%) patient (p=0.405). Reintervention free median survival was 100 (95%CI 9.87-190.12) days in the SWS group and 164 (95%CI 136.61-191.39) days in EUS-HGS group (p=0.690). Overall survival after reintervention was 153 days in SWS group and 164 days in the EUS-HGS group (p=0.996).

Conclusions EUS-HGS is not superior to SWS in terms of functional success, need for reintervention, reintervention free survival and overall survival in patients with blocked biliary metal endoprosthesis.

Publication History

Article published online:
27 March 2025