Feasibility of therapeutic endoscopic ultrasound in the bridge-to-surgery scenario: The example of pancreatic adenocarcinoma

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.

Automated summary

Upfront resection is less common for pancreatic ductal adenocarcinoma, and neoadjuvant treatments are increasingly used. However, complications such as jaundice, gastric outlet obstruction, and acute cholecystitis can lead to chemotherapy discontinuation, making effective management of these complications crucial. t-EUS has a high efficacy-invasiveness ratio compared to other methods, making it a powerful tool against chemotherapy discontinuation and potentially increasing subsequent resectability. Restricting t-EUS in potential surgical candidates is unsupported by evidence.