EUS-Gallbladder vs CDS as First Line in MBDO- Palliative (CARPEGIEM Trial)

Biliary Tract Neoplasms Clinical Trial

— CARPEGIEM  

Official title:

Multicenter Study of EUS-guided Gallbladder Drainage vs Choledochoduodenostomy as First Line in Malignant Distal Obstruction in Palliative Patients (CARPEGIEM Trial): an Open-label, Randomized Controlled Clinical Trial

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT06375967
• Other study ID #: CARPEGIEM
• Status: Not yet recruiting
• Phase: N/A
• Start date: June 2024
• Est. completion date: June 2027

Study information

• Verified date: November 2023
• Source: Hospital Universitari de Bellvitge
• Contact: Julia Escuer Turu, MD, Research fellow
• Phone: 618272824
• Email: carpegiem.trial[@]gmail.com
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The aim of the study is to evaluate technical, clinical and safety outcomes of lumen-apposing metal stent (LAMS) with a coaxial double-pigtail plastic stent (DPS) in EUS-guided choledochoduodenostomies vs cholcystogastrostomy for the management of malignant biliary obstruction in palliative patients.

Description:

Ecoendoscopy-guided choledochoduodenostomy (EUS-CDS) with a biliary lumen-apposing metal stent (LAMS) has been widely accepted as a second line treatment in cases of ERCP failure in malignant distal biliary obstruction (MDBO). Recent studies (DRAMBO and ELEMENT trial) compared EUS-CDS vs ERCP as a first line treatment in MDBO in palliative patients, showing similar clinical and techinal success and adverse events rate between both techniques, demonstrating that both procedures could be options for primary biliary drainage in unresectable MDBO.

Furthermore a recent clinical trial (BAMPI trial) has proven that the addition of a coaxial double pigtail (DPS) offers benefits in terms of safey and clinical success.

In the last years there has been an increasing interest for the EUS-guided gallblader drainage (EUS-GBD) in unresectable MDBO as an alternative for EUS-CDS, and recent studies and reviews have been reported with acceptable techinal and clinical success, but no clinical trial has been performed up to date.

Our hypothesis is that EUS-GBD may offer benefits in terms of safety over EUS-CDS, maintaining similar clinical and techinal success rates.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 128
• Est. completion date: June 2027
• Est. primary completion date: June 2026
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 100 Years

Eligibility

Inclusion Criteria:

• Malignant distal biliary obstruction diagnosed in patient considered PALIATIVE with biliary drainage indication.

• Consensual malignancy by a bilio-pancreatic multidisciplinar committe (histological confirmation is not mandatory)

• Patient capable of understanding and/or singning the informed consent.

• Patient who understands the type of study and will comply with all follow-up tests throughout its duration

Exclusion Criteria:

• Pregnancy or lactation.

• Severe coagulation disorder: INR > 1.5 non correctable with plasma administration and/or platelet count < 50.000/mm3.

• Previous cholecistectomy or gallblader perforation.

• Tumoral obstruction of cystic duct.

• Multiple liver metastases affecting more than 30% of the liver parenchyma

• Distal malignant biliary strictures in patients considered resectable or borderline.

• Benign or uncertain etiology of biliary strictures or strictures located proximally or in close proximity to the hilum.

• Patients with prior biliary stents or other biliary drainages (e.g., PTCD).

• Altered intestinal anatomy due to prior surgery that prevents or hinders papillary access ______________ (e.g., gastric bypass, Billroth II, duodenal switch, Roux-en-Y).

• Gastric outlet obstruction.

• Situations that do not allow for upper gastrointestinal endoscopy (e.g., esophageal stricture).

• Patients with functional diversity, who lack the capacity to understand the nature and potential consequences of the study, except when a legal representative is available.

• Patients incapable of maintaining follow-up appointments (lack of adherence).

• Lack of informed consent.

Related Conditions & MeSH terms

• Biliary Tract Neoplasms
• Malignant Biliary Obstruction
• Pancreatic Cancer Non-resectable

Intervention

Procedure:
• Endoscopic biliary drainage
Decompression of the bile duct by endoscopic aproach.

Device:
• Lumen-apposing metal stent (LAMS) and double-pigtail plastic stent (DPPS)
Lumen-apposing metal stent (LAMS) with coaxial double-pigtail plastic stent (DPPS) deployment: LAMS size: 6x8mm, 8x8mm. Consider 10x10mm or 10x15mm if abundant pathological material in gallblader. DPPS size: 7Fr x 3-5-7cm.
• Lumen-apposing metal stent (LAMS) and double-pigtail plastic stent (DPPS)
Lumen-apposing metal stent (LAMS) with coaxial double-pigtail plastic stent (DPPS) deployment: LAMS size: 6x8mm or 8x8mm. Consider 10x10mm if bile duct > 18mm. DPPS size: 7Fr x 3-7cm.

Locations

Country	Name	City	State
Spain	Hospital Universitari de Bellvitge	L'Hospitalet De Llobregat	Barcelona, Catalonia

Sponsors (12)

Lead Sponsor

Collaborator

Hospital Universitari de Bellvitge

Complejo Hospitalario de Navarra, Complejo Hospitalario Universitario de Santiago, Complejo Hospitalario Universitario de Vigo, Hospital Clínico Universitario de Valencia, Hospital de Sant Pau, Hospital General Universitario de Alicante, Hospital General Universitario de Castellón, Hospital Mutua de Terrassa, Hospital Universitario Ramon y Cajal, University Hospital Virgen de las Nieves, University of Salamanca

Country where clinical trial is conducted

Spain, 

References & Publications (6)

Binda C, Anderloni A, Fugazza A, Amato A, de Nucci G, Redaelli A, Di Mitri R, Cugia L, Pollino V, Macchiarelli R, Mangiavillano B, Forti E, Brancaccio ML, Badas R, Maida M, Sinagra E, Repici A, Fabbri C, Tarantino I. EUS-guided gallbladder drainage using a lumen-apposing metal stent as rescue treatment for malignant distal biliary obstruction: a large multicenter experience. Gastrointest Endosc. 2023 Nov;98(5):765-773. doi: 10.1016/j.gie.2023.06.054. Epub 2023 Jun 29. — View Citation

Chen YI, Callichurn K, Chatterjee A, Desilets E, Fergal D, Forbes N, Gan I, Kenshil S, Khashab MA, Kunda R, Lam E, May G, Mohamed R, Mosko J, Paquin SC, Sahai A, Sandha G, Teshima C, Barkun A, Barkun J, Bessissow A, Candido K, Martel M, Miller C, Waschke K, Zogopoulos G, Wong C; ELEMENT trial and for the Canadian Endoscopic Research Collaborative (CERC). ELEMENT TRIAL: study protocol for a randomized controlled trial on endoscopic ultrasound-guided biliary drainage of first intent with a lumen-apposing metal stent vs. endoscopic retrograde cholangio-pancreatography in the management of malignant distal biliary obstruction. Trials. 2019 Dec 9;20(1):696. doi: 10.1186/s13063-019-3918-y. — View Citation

Garcia-Sumalla A, Loras C, Sanchiz V, Sanz RP, Vazquez-Sequeiros E, Aparicio JR, de la Serna-Higuera C, Luna-Rodriguez D, Andujar X, Capilla M, Barbera T, Foruny-Olcina JR, Martinez B, Dura M, Salord S, Laquente B, Tebe C, Videla S, Perez-Miranda M, Gornals JB; Spanish Working Group on Endoscopic Ultrasound Guided Biliary Drainage. Multicenter study of lumen-apposing metal stents with or without pigtail in endoscopic ultrasound-guided biliary drainage for malignant obstruction-BAMPI TRIAL: an open-label, randomized controlled trial protocol. Trials. 2022 Feb 25;23(1):181. doi: 10.1186/s13063-022-06106-1. Erratum In: Trials. 2022 Mar 14;23(1):214. — View Citation

Kamal F, Khan MA, Lee-Smith W, Sharma S, Acharya A, Farooq U, Aziz M, Kouanda A, Dai SC, Munroe CA, Arain M, Adler DG. Efficacy and safety of EUS-guided gallbladder drainage for rescue treatment of malignant biliary obstruction: A systematic review and meta-analysis. Endosc Ultrasound. 2023 Jan-Feb;12(1):8-15. doi: 10.4103/EUS-D-21-00206. — View Citation

Mangiavillano B, Moon JH, Facciorusso A, Vargas-Madrigal J, Di Matteo F, Rizzatti G, De Luca L, Forti E, Mutignani M, Al-Lehibi A, Paduano D, Bulajic M, Decembrino F, Auriemma F, Franchellucci G, De Marco A, Gentile C, Shin IS, Rea R, Massidda M, Calabrese F, Mirante VG, Ofosu A, Crino SF, Hassan C, Repici A, Larghi A. Endoscopic ultrasound-guided gallbladder drainage as a first approach for jaundice palliation in unresectable malignant distal biliary obstruction: Prospective study. Dig Endosc. 2024 Mar;36(3):351-358. doi: 10.1111/den.14606. Epub 2023 Jul 3. — View Citation

Teoh AYB, Napoleon B, Kunda R, Arcidiacono PG, Kongkam P, Larghi A, Van der Merwe S, Jacques J, Legros R, Thawee RE, Saxena P, Aerts M, Archibugi L, Chan SM, Fumex F, Kaffes AJ, Ma MTW, Messaoudi N, Rizzatti G, Ng KKC, Ng EKW, Chiu PWY. EUS-Guided Choledo — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	SAFETY (ADVERSE EVENTS)	Safety will be measured by careful and comparative evaluation of adverse effects in both groups.	12 months
Primary	Recurrent biliary obstruction	Recurrent biliary obstruction (RBO) has been defined as a composite endpoint of either occlusion or migration.	12 months
Secondary	CLINICAL SUCCESS	Resolution of jaundice or drop in total bilirubin level by > 50% within 2 weeks after the EUS guided drainage.	2 weeks
Secondary	TECHNICAL SUCCESS	Technical success was defined as successful placement of the LAMS between the bile duct (choledoc or gallblader) and the lumen digestive system (stomach or duodenum), creating a transmural ostomy. To evaluate the correct position of the transmural stent, the deployment of the internal flap in the lumen of the bile duct must be verified by ultrasound vision and the internal flap by endoscopic vision.	24 hours
Secondary	BILIARY REINTERVENTIONS (BRI)	Interventions needed to treat - Recurrent biliary obstruction (RBO) has been defined as a composite endpoint of either occlusion or migration.	12 months
Secondary	HOSPITAL STAY	Length of hospital stay after intervention	12 months
Secondary	MORTALITY	Overall mortality throughout the study	12 months
Secondary	COST ANALYSIS	Evaluate the costs between the two types of strategy	12 months