EVERSON LUIZ DE ALMEIDA ARTIFON
Projetos de Pesquisa
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LIM/26 - Laboratório de Pesquisa em Cirurgia Experimental, Hospital das Clínicas, Faculdade de Medicina - Líder
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- EUS-Guided Biliary Drainage Versus ERCP in Malignant Biliary Obstruction Before Hepatobiliary Surgery(2023) TYBERG, Amy; SARKAR, Avik; SHAHID, Haroon M.; SHAH-KHAN, Sardar M.; GAIDHANE, Monica; SIMON, Alexa; EISENBERG, Ian A.; LAJIN, Michael; KARAGYOZOV, Petko; LIAO, Kelvin; PATEL, Roohi; ZHAO, Eric; MARTINEZ, Ma Guadalupe; ARTIFON, Everson L.; LINO, Andre D.; VANELLA, Giuseppe; ARCIDIACONO, Paolo G.; KAHALEH, MichelIntroduction:Endoscopic ultrasound-guided biliary drainage (EUS-BD) is the procedure of choice for patients who cannot undergo endoscopic retrograde cholangiopancreatography (ERCP). The outcomes of patients undergoing surgery after EUS-BD for malignancy are unknown.Methods:We conducted an international, multicenter retrospective comparative study of patients who underwent hepatobiliary surgery after having undergone EUS-BD or ERCP from 6 tertiary care centers. Patient demographics, procedural data, and follow-up care were collected in a registry.Results:One hundred forty-five patients were included: EUS-BD n=58 (mean age 66, 45% male), ERCP n=87 (mean age 68, 53% male). The majority of patients had pancreatic cancer, cholangiocarcinoma, or gallbladder malignancy. In the EUS-BD group, 29 patients had hepaticogastrostomy, 24 had choledochoduodenostomy, and 5 had rendezvous technique done. The most common surgery was Whipple in both groups (n=41 EUS-BD, n=56 ERCP) followed by partial hepatectomy (n=7 EUS-BD, n=14 ERCP) and cholecystectomy (n=2 EUS-BD, n=2 ERCP). Endoscopy clinical success was comparable in both groups (98% EUS-BD, 94% ERCP). Adverse event rates were similar in both groups: EUS-BD (n=10, 17%) and ERCP (n=23, 26%). Surgery technical success and clinical success were significantly higher in the EUS-BD group compared with the ERCP group (97% vs. 83%, 97% vs. 75%). Total Hospital stay from surgery to discharge was significantly higher in the ERCP group (19 d vs. 10 d, P=0.0082).Discussion:Undergoing EUS-BD versus ERCP before hepatobiliary surgery is associated with fewer repeat endoscopic interventions, shorter duration between endoscopy and surgical intervention, higher rates of surgical clinical success, and shorter length of hospital stay after surgery.
- EUS-guided Choledochoduodenostomy Versus Hepaticogastrostomy A Systematic Review and Meta-analysis(2018) UEMURA, Ricardo S.; KHAN, Muhammad Ali; OTOCH, Jose P.; KAHALEH, Michel; MONTERO, Edna F.; ARTIFON, Everson L. A.Background and Aims: Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative in cases of endoscopic retrograde cholangiopancreatography (ERCP) failure. Two types of EUS-BD methods for achieving biliary drainage when ERCP fails are choledochoduodenostomy (CDS) or hepaticogastrostomy (HGS). However, there is no consensus if one approach is better than the other. Therefore, we conducted a systematic review and meta-analysis to evaluate these 2 main EUS-BD methods. Methods: We searched MEDLINE, Embase, Scopus, Cochrane database, LILACS from inception through April 8, 2017, using the following search terms in various combinations: biliary drainage, biliary stent, transluminal biliary drainage, choledochoduodenostomy, hepaticogastrostomy, endoscopic ultrasound-guided biliary drainage. We selected studies comparing CDS and HGS in patients with malignant biliary obstruction with ERCP failure. Pooled odds ratio (OR) were calculated for technical success, clinical success, and adverse events and difference of means calculated for duration of procedure and survival after procedure. Results: A total of 10 studies with 434 patients were included in the meta-analysis: 208 underwent biliary drainage via HGS and the remaining 226 via CDS. The technical success for CDS and HGS was 94.1% and 93.7%, respectively, pooled OR = 0.96 [95% confidence interval (CI) = 0.39-2.33, I-2 = 0%]. Clinical success was 88.5% in CDS and 84.5% in HGS, pooled OR = 0.76 (95% CI = 0.42-1.35, I-2 = 17%). There was no difference for adverse events OR = 0.97 (95% CI = 0.60-1.56), I-2 = 37%. CDS was about 2 minutes faster with a pooled difference in means of was -2.69 (95% CI = -4.44 to -0.95). Conclusion: EUS-CDS and EUS-HGS have equal efficacy and safety, and are both associated with a very high technical and clinical success. The choice of approach may be selected based on patient anatomy.
- Photodynamic Therapy (PDT), Radiofrequency Ablation (RFA) With Biliary Stents in Palliative Treatment of Unresectable Extrahepatic Cholangiocarcinoma A Systematic Review and Meta-analysis(2022) MOHAN, Babu P.; CHANDAN, Saurabh; KHAN, Shahab R.; KASSAB, Lena L.; PONNADA, Suresh; ARTIFON, Everson L. A.; OTOCH, Jose P.; MCDONOUGH, Stephanie; ADLER, Douglas G.Background and Aim: Extrahepatic unresectable cholangiocarcinoma carries a dismal prognosis. In addition to biliary drainage by stent placement; photodynamic therapy (PDT) and radiofrequency ablation (RFA) have been tried to prolong survival. In this meta-analysis, we appraise the current known data on the use of PDT, RFA in the palliative treatment of extrahepatic unresectable cholangiocarcinoma. Methods: We searched multiple databases from inception through July 2020 to identify studies that reported on PDT and RFA. Pooled rates of survival, stent patency, 30-, 90-day mortality, and adverse events were calculated. Study heterogeneity was assessed using I (2)% and 95% prediction interval. Results: A total of 55 studies (2146 patients) were included. A total of 1149 patients underwent treatment with PDT (33 studies), 545 with RFA (22 studies), and 452 patients with stent-only strategy. The pooled survival rate with PDT, RFA, and stent-only groups was 11.9 [95% confidence interval (CI): 10.7-13.1] months, 8.1 (95% CI: 6.4-9.9) months, and 6.7 (95% CI: 4.9-8.4) months, respectively. The pooled time of stent patency with PDT, RFA, and stent-only groups was 6.1 (95% CI: 4.2-8) months, 5.5 (95% CI: 4.2-6.7) months, and 4.7 (95% CI: 2.6-6.7) months, respectively. The pooled rate of 30-day mortality with PDT was 3.3% (95% CI: 1.6%-6.7%), with RFA was 7% (95% CI: 4.1%-11.7%) and with stent-only was 4.9% (95% CI: 1.7%-13.1%). The pooled rate of 90-day mortality with PDT was 10.4% (95% CI: 5.4%-19.2%) and with RFA was 16.3% (95% CI: 8.7%-28.6%). Conclusion: PDT seemed to demonstrate better overall survival and 30-day mortality rates than RFA and/or stent-only palliation.
- Endoscopic Ultrasound-assisted Bile Duct Access and Drainage Multicenter, Long-term Analysis of Approach, Outcomes, and Complications of a Technique in Evolution(2014) GUPTA, Kapil; PEREZ-MIRANDA, Manuel; KAHALEH, Michel; ARTIFON, Everson L. A.; ITOI, Takao; FREEMAN, Martin L.; DE-SERNA, Carlos; SAUER, Bryan; GIOVANNINI, MarcBackground and Study Aims:When endoscopic retrograde cholangio-pancreatography fails, the bile duct is drained percutaneously or surgically. Evolution of endoscopic ultrasound (EUS) has provided the ability to visualize and also drain the biliary tree. The aim of this study was to review different techniques of EUS-guided bile duct access and drainage, and compare extrahepatic (EH) and intrahepatic (IH) approaches and benign with malignant indications.Patients and Methods:EUS-guided attempts at bile duct drainage from 6 international centers were reviewed. This is a multicenter, nonrandomized retrospective study.Results:Two hundred forty patients underwent EUS-guided bile duct access and drainage (EUS-BD) with a mean age of 67.3 years. The IH approach was used in 60% of the cases. In 99% of the subjects, a 19-G needle was used. Success was achieved in 87% cases, with a similar success rate in EH and IH approaches (84.3% vs. 90.4%; P=0.15). Metal stents were placed in 60% and plastic stents in 27% of the cases. A higher success rate was noted in malignant diseases compared with benign diseases (90.2% vs. 77.3%; P=0.02). Complications for all techniques included pneumoperitoneum 5%, bleeding 11%, bile leak/peritonitis 10%, and cholangitis 5%. No significant difference was noted between the IH and the EH approaches (32.6% vs. 35.6%; P=0.64), with similar rates in benign and malignant diseases (26.7% vs. 37.1%; P=0.19).Conclusions:The EUS-BD technique is currently limited by a lack of dedicated devices and large data reporting outcomes and complications. Larger prospective and multicenter studies are needed to better define the indications, outcomes, and complications. With greater experience and dedicated devices, EUS-BD can be an effective alternative.
- Biliary Drainage in Patients With Unresectable, Malignant Obstruction Where ERCP Fails Endoscopic Ultrasonography-Guided Choledochoduodenostomy Versus Percutaneous Drainage(2012) ARTIFON, Everson L. A.; APARICIO, Dayse; PAIONE, Jose B.; LO, Simon K.; BORDINI, Andre; RABELLO, Carolina; OTOCH, Jose P.; GUPTA, KapilBackground: Endoscopic retrograde cholangiopancreatography may fail because of malignant involvement of the second portion of the duodenum and the major papilla. Alternatives include percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CD) has been reported as an alternative. Objective: To prospectively compare EUS-CD and PTBD in patients with unresectable malignant biliary obstruction. Design: Prospective and randomized study. Setting: Tertiary center. Main Outcome Measurements: Success and efficacy comparison EUS-CD with PTBD. Results: Twenty-five subjects were randomized (13 EUS-CD and 12 PTBD). Mean age was 67 years (SD, 11.9). The 2 groups were similar before intervention in terms of quality of life [EUS-CD (58.3) vs. PTBD (57.8); P = 0.78], total bilirubin (16.4 vs. 17.2; P = 0.7), alkaline phosphatase (539 vs. 518; P = 0.7), and gamma-glutamyl transferase (554.3 vs. 743.5; P = 0.56). All procedures were technically and clinically successful in both groups. At 7-day follow-up there was a significant reduction in total bilirubin in both the groups (EUS-CD, 16.4 to 3.3; P = 0.002 and PTBD, 17.2 to 3.8; P = 0.01), although no difference was noted comparing the 2 groups (EUS-CD to PTBD; 3.3 vs. 3.8; P = 0.2). There was no difference between the complication rates in the 2 groups (P = 0.44), EUS-CD (2/13; 15.3%) and PTBD (3/12; 25%). Costs were similar in the 2 groups also ($5673-EUS-CD vs. $7570-PTBD; P = 0.39). Limitations: Small sample size and single center study. Conclusions: EUS-CD can be an effective and safe alternative to PTBD with similar success, complication rate, cost, and quality of life.