Recanalization after biliojejunostomy by use of a new digital per-oral cholangioscope through the hepaticogastrostomy route

Peroral Cholangioscopy: How Technology and Imaging Have Changed ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is the minimally invasive standard of care for the treatment of several biliary and pancreatic pathologies. One of the limitations of this technique is the lack of endoluminal vision within the biliary tree or Wirsung's duct. This limits the diagnostic accuracy of the procedure and reduces the effectiveness of many treatments. Technological progress and the use of increasingly ergonomic and high-definition imaging equipment have led to the dissemination of peroral cholangioscopy (POC). Thanks to the high quality of video image resolution, POC could well be a powerful tool used to characterize malignant biliary strictures. It could also allow targeted biopsies or local treatments, hence reducing the risk of complications and increasing outcomes. The technological improvement of the last generation of POC is opening new horizons in the treatment of biliopancreatic pathologies, thereby contributing to refine and enhance the ERCP management of several diseases in the near future.

EUS-guided biliary drainage for the management of benign biliary strictures in patients with altered anatomy: A single-center experience

Background and Objectives:

The management of benign biliary stricture in patients with altered anatomy secondary to surgery is challenging. Percutaneous transhepatic biliary drainage (BD) represents the standard therapy for benign biliary stricture, but it is associated with nontrivial morbidity rates. Despite the increasing application of guided BD (EUS-BD) for the management of malignant obstruction, its role in patients with benign biliary stricture is limited. This retrospective study aimed to evaluate the feasibility, safety, and clinical effectiveness of EUS-BD with multiple transanastomotic plastic stent treatment in patients with benign biliary stricture.

Materials and Methods:

This study included consecutive patients who underwent EUS-BD for benign biliary stenosis at our center. EUS-BD with fully covered self-expandable metal stent placement was performed first. When feasible, the stricture was treated by balloon dilation with the placement of a transanastomotic double-pigtail plastic stent. Scheduled procedures were repeated to remove the metal stent and replace the plastic stent to treat the stenosis. Technical success and adverse events (AEs) were assessed.

Results:

Twelve patients underwent EUS-BD for benign biliary strictures. Procedural and clinical successes were achieved in all patients (100%). Multistenting treatment was performed in 10/12 patients (77%). The median number of stents inserted, maximum number of stents placed, and median time of retreatment were 2.4 (range: 1–4), 4, and 3.4 (range: 1–7), respectively. In total, 4/12 patients (33.3%) developed AEs that required endoscopic interventions (Clavien-Dindo Grade III).

Conclusions:

EUS-BD with the placement of multiple trans-stenosis plastic stents is a safe, feasible, and well-tolerated alternative for the management of benign biliary stricture in patients with surgery-altered anatomy. Long-term follow-up is necessary to support our results.

Interventional endoscopic ultrasonography for benign biliary diseases in patients with surgically altered anatomy

PURPOSE OF REVIEW

At present, balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of therapy for benign biliary diseases in patients with surgically altered anatomy (SAA). Recently interventional endoscopic ultrasonography (EUS) techniques have been used for not only drainage procedure but also treatment procedure in such patients. This review aims to discuss details about interventional EUS techniques in such patients and published clinical data.

RECENT FINDINGS

Antegrade treatment such as antegrade stone removal for bile duct stones or guidewire manipulation across the anastomotic stricture following antegrade balloon dilation and antegrade stenting for the stricture via the approach route created by EUS-bilioenterostomy, so-called EUS-guided antegrade intervention, have been developed. In difficult cases, per-oral cholangioscopy-assisted antegrade intervention has been reported as a useful technique. In addition, other novel alternative interventional EUS techniques have been also reported such as EUS-directed transgastric ERCP in patients with Roux-en-Y gastric bypass.

SUMMARY

Interventional EUS techniques appear to be feasible and safe alternative procedures for benign biliary diseases in patients with SAA after balloon enteroscopy-assisted ERCP failure.