A Systematic Review of Endoscopic Treatments for Concomitant Malignant Biliary Obstruction and Malignant Gastric Outlet Obstruction and the Outstanding Role of Endoscopic Ultrasound-Guided Therapies

SIMPLE SUMMARY: Palliation of gastric outlet obstruction (GOO) and obstructive jaundice due to malignancy is a fundamental step in improving quality of life (QoL) and initiating or restarting systemic oncologic therapy in these patients. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is still the primary treatment for malignant biliary obstruction (MBO), but it fails more frequently when GOO is concomitant. Poor quality studies are present in the medical literature on the application of endoscopic ultrasound (EUS) guided procedures among patients suffering from double obstruction, and few studies explore outcomes when endoscopy is performed during the same session or within a few days. Our aim was to systematically search the evidence supporting the use of EUS-guided procedures in this scenario in order to evaluate the best strategy for concomitant treatment of MBO and MGOO. ABSTRACT: Background: The treatments for cancer palliation in patients with concomitant malignant biliary obstruction (MBO) and gastric outlet obstruction (MGOO) are still under investigation due to the lack of evidence available in the medical literature. We performed a systematic search and critical review to investigate efficacy and safety among patients with MBO and MGOO undergoing both endoscopic ultrasound-guided biliary drainage (EUS-BD) and MGOO endoscopic treatment. Methods: A systematic literature search was performed in PubMed, MEDLINE, EMBASE, and the Cochrane Library. EUS-BD included both transduodenal and transgastric techniques. Treatment of MGOO included duodenal stenting or EUS-GEA (gastroenteroanastomosis). Outcomes of interest were technical success, clinical success, and rate of adverse events (AEs) in patients undergoing double treatment in the same session or within one week. Results: 11 studies were included in the systematic review for a total number of 337 patients, 150 of whom had concurrent MBO and MGOO treatment, fulfilling the time criteria. MGOO was treated by duodenal stenting (self-expandable metal stents) in 10 studies, and in one study by EUS-GEA. EUS-BD had a mean technical success of 96.4% (CI 95%, 92.18–98.99) and a mean clinical success of 84.96% (CI 95%, 67.99–96.26). The average frequency of AEs for EUS-BD was 28.73% (CI 95%, 9.12–48.33). Clinical success for duodenal stenting was 90% vs. 100% for EUS-GEA. Conclusions: EUS-BD could become the preferred drainage in the case of double endoscopic treatment of concomitant MBO and MGOO in the near future, with the promising EUS-GEA becoming a valid option for MGOO treatment in these patients.