Opinion Review
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 14, 2022; 28(10): 976-984
Published online Mar 14, 2022. doi: 10.3748/wjg.v28.i10.976
Feasibility of therapeutic endoscopic ultrasound in the bridge-to-surgery scenario: The example of pancreatic adenocarcinoma
Giuseppe Vanella, Domenico Tamburrino, Gabriele Capurso, Michiel Bronswijk, Michele Reni, Giuseppe Dell'Anna, Stefano Crippa, Schalk Van der Merwe, Massimo Falconi, Paolo Giorgio Arcidiacono
Giuseppe Vanella, Gabriele Capurso, Giuseppe Dell'Anna, Paolo Giorgio Arcidiacono, Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
Domenico Tamburrino, Stefano Crippa, Massimo Falconi, Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan 20132, Italy
Michiel Bronswijk, Schalk Van der Merwe, Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven 3000, Belgium
Michiel Bronswijk, Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden 2820, Belgium
Michele Reni, Department of Medical Oncology, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
Author contributions: Vanella G, Capurso G and Arcidiacono PG conceived the manuscript; Vanella G, Bronswijk M and Tamburrino D performed the literature search; Vanella G, Bronswijk M, Tamburrino D, Dell’Anna G and Capurso G drafted the paper; Arcidiacono PG, Reni M, Crippa S, Van der Merwe S and Falconi M critically revised the manuscript for important intellectual content; Vanella G created the figures; all authors agreed on the final submitted version, accepting to be accountable for accuracy or integrity of any part of the work.
Conflict-of-interest statement: Michiel Bronswijk has consultancy agreements with Prion Medical and Taewoong. Schalk van der Merwe holds the Cook Medical and Boston Scientific chair in Interventional Endoscopy and holds consultancy agreements with Cook Medical, Pentax and Olympus. The remaining authors declare no conflict of interest relevant for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Paolo Giorgio Arcidiacono, FASGE, MD, Associate Professor, Director, Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, Milan 20132, Italy. arcidiacono.paologiorgio@hsr.it
Received: August 20, 2021
Peer-review started: August 20, 2021
First decision: October 2, 2021
Revised: October 4, 2021
Accepted: February 15, 2022
Article in press: February 15, 2022
Published online: March 14, 2022
Abstract

Upfront resection is becoming a rarer indication for pancreatic ductal adenocarcinoma, as biologic behavior and natural history of the disease has boosted indications for neoadjuvant treatments. Jaundice, gastric outlet obstruction and acute cholecystitis can frequently complicate this window of opportunity, resulting in potentially deleterious chemotherapy discontinuation, whose resumption relies on effective, prompt and long-lasting management of these complications. Although therapeutic endoscopic ultrasound (t-EUS) can potentially offer some advantages over comparators, its use in potentially resectable patients is primal and has unfairly been restricted for fear of potential technical difficulties during subsequent surgery. This is a narrative review of available evidence regarding EUS-guided choledochoduodenostomy, gastrojejunostomy and gallbladder drainage in the bridge-to-surgery scenario. Proof-of-concept evidence suggests no influence of t-EUS procedures on outcomes of eventual subsequent surgery. Moreover, the very high efficacy-invasiveness ratio over comparators in managing pancreatic cancer-related symptoms or complications can provide a powerful weapon against chemotherapy discontinuation, potentially resulting in higher subsequent resectability. Available evidence is discussed in this short paper, together with technical notes that might be useful for endoscopists and surgeons operating in this scenario. No published evidence supports restricting t-EUS in potential surgical candidates, especially in the setting of pancreatic cancer patients undergoing neoadjuvant chemotherapy. Bridge-to-surgery t-EUS deserves further prospective evaluation.

Keywords: Endosonography, Gastrojejunostomy, Choledochoduodenostomy, Gallbladder drainage, Pancreatic cancer, Pancreatic surgery

Core Tip: Despite the increase of a subset of patients with pancreatic adenocarcinoma undergoing neoadjuvant chemotherapy, therapeutic endoscopic ultrasound (EUS) has been unfairly restricted in potentially resectable patients. However, to date, no evidence suggests any influence of therapeutic EUS procedures on difficulty or outcomes of eventual subsequent surgery. Conversely, proof-of-concept papers have described uncomplicated surgery following EUS-guided gallbladder drainage, choledochoduodenostomy and gastrojejunostomy. Available evidence and technical notes are collected in this review. Due to the very high efficacy-invasiveness ratio of therapeutic EUS procedures, potentially resulting in less chemotherapy discontinuation, we believe that their use should not be restricted in the bridge-to-surgery scenario while implementing its prospective evaluation.