Published online Mar 14, 2022. doi: 10.3748/wjg.v28.i10.976
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
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.
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.