Novel method of endoscopic ultrasound-guided hepaticogastrostomy to prevent stent dysfunction

Is Endoscopic Ultrasound-Guided Hepaticogastrostomy Safe and Effective after Failed Endoscopic Retrograde Cholangiopancreatography?-A Systematic Review and Meta-Analysis

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative option for biliary drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). Limited data exist on the safety and efficacy of EUS-HGS. In this comprehensive meta-analysis, we aim to study the safety and efficacy of EUS-HGS in cases of failed conventional ERCP. Methods: Embase, PubMed, and Web of Science databases were searched to include all studies that evaluated the efficacy and safety of EUS-HGS. Using the random effect model, the pooled weight-adjusted event rate estimate for clinical outcomes in each group were calculated with 95% confidence intervals (CIs). The primary outcomes were technical and clinical success rates. Secondary outcomes included overall adverse events (AEs), rates of recurrent biliary obstruction (RBO), and rates or re-intervention. Results: Our analysis included 70 studies, with a total of 3527 patients. The pooled technical and clinical success rates for EUS-HGS were 98.1% ([95% CI, 97.5-98.7]; I2 = 40%) and 98.1% ([95% CI, 97.5-98.7]; I2 = 40%), respectively. The pooled incidence rate of AEs with EUS-HGS was 14.9% (95% CI, 12.7-17.1), with bile leakage being the most common (2.4% [95% CI, 1.7-3.2]). The pooled incidence of RBO was 15.8% [95% CI, 12.2-19.4], with a high success rate for re-intervention (97.5% [95% CI, 94.7-100]). Conclusions: Our analysis showed high technical and clinical success rates of EUS-HGS, making it a feasible and effective alternative to ERCP. The ongoing development of dedicated devices and techniques is expected to make EUS-HGS more accessible and safer for patients in need of biliary drainage.

Outcomes of partially covered self-expandable metal stents with different uncovered lengths in endoscopic ultrasound-guided hepaticogastrostomy: a Japanese retrospective study

BACKGROUND/AIMS

The optimal length of the uncovered portion of partially covered self-expandable metal stents (PCSEMSs) used in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) remains unclear. This study investigated the safety and efficacy of PCSEMSs with different uncovered lengths, with a focus on stent migration and time to recurrent biliary obstruction (RBO).

METHODS

Outcomes of patients undergoing EUS-HGS using PCSEMSs with 5-mm and 20-mm uncovered portions at our institution from January 2016 to December 2021 were compared.

RESULTS

Sixty-two patients underwent EUS-HGS using PCSEMS (5/20-mm uncovered portions: 32/30). Stent migration occurred only in the 5-mm group. There were no differences in RBO rates (28.1% vs. 40.0%) or median time to RBO (6.8 vs. 7.1 months) between the two groups. Median overall survival (OS) was longer in the 20-mm group (3.1 vs. 4.9 months, p=0.037) due to the higher number of patients that resumed chemotherapy after EUS-HGS (56.7% vs. 28.1%, p=0.029). Good performance status, absence of hepatic metastases, and chemotherapy after EUS-HGS were independent predictors of longer OS.

CONCLUSIONS

No migration was observed in patients treated with PCSEMS with 20-mm uncovered portions. Patients treated with PCSEMS with 20-mm uncovered portions performed at least as well as those treated with 5-mm uncovered portions in all material respects.

Preliminary feasibility study of a new partially covered self-expandable metal stent with an anchoring flange for EUS-guided hepaticogastrostomy (with videos)

BACKGROUND AND AIMS

EUS-guided hepaticogastrostomy (EUS-HPG) has a risk of serious procedural adverse events (AEs), but few dedicated devices for EUS-HPG are available. We evaluated the feasibility of a new partially covered self-expandable metal stent (PCSEMS) with an anchoring flange for EUS-HPG.

METHODS

The feasibility of a stent featuring a proximal radiopaque uncovered portion 1.5 cm in length and a distal anchoring flange 20 mm in diameter was evaluated in consecutive patients undergoing EUS-HPG for unresectable malignant biliary obstruction. Primary outcomes were the technical and clinical success of EUS-HPG, and secondary outcomes were AEs, recurrent biliary obstruction (RBO), reintervention for RBO, and the technical feasibility of peroral cholangioscopy (POC) through the stent in situ.

RESULTS

EUS-HPG was performed in 24 patients with unresectable malignant biliary obstruction. The technical and clinical success rates of EUS-HPG were 100% (24/24) and 91.7% (22/24), respectively. AEs developed after EUS-HPG in 8.3% of patients (2/24, cholangitis). RBO developed in 29.2% of patients (7/24), with a median cumulative time to RBO of 6.7 months. The causes of RBO were sludge formation (n = 4), hyperplasia at an uncovered portion (n = 2), and nonocclusive cholangitis (n = 1). Reintervention for RBO had a 100% success rate (7/7), and POC through the stent in situ was technically feasible in 7 of 8 patients with a stent diameter of 10 mm.

CONCLUSIONS

EUS-HPG with a new PCSEMS can alleviate malignant biliary obstruction after failed ERCP. The novel stent evaluated in this study may prevent stent-related AEs, including stent migration, and allow advanced endoscopic interventions through the HPG route.

Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.

METHODS

A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.

RESULTS

One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%).

CONCLUSIONS

Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.

Complete migration of a fully covered self-expandable metallic stent after endoscopic ultrasound-guided hepaticogastrostomy: A case report

A male patient underwent gastrojejunal bypass surgery in 2017. In 2020, he was referred to our hospital for suspected obstructive jaundice. Subsequently, he was diagnosed with cholangiocarcinoma, and endoscopic retrograde cholangiopancreatography was attempted via balloon-assisted enteroscopy. However, the endoscope did not reach the duodenal papilla owing to the abdomen-small intestine adhesion. Therefore, endoscopic ultrasound-guided hepaticogastrostomy was performed using a dedicated plastic stent. After stent placement, obstructive jaundice and cholangitis promptly improved. However, we replaced the plastic stent with a fully covered self-expandable metal stent because stent occlusions occurred frequently. Two months after fully covered self-expandable metal stent placement, the patient developed cholangitis again. Notably, during the endoscopic procedure, the stent was found to be completely migrated. Nevertheless, the fistula was still open, and the patient was successfully retreated with the maintained fistula of endoscopic ultrasound-guided hepaticogastrostomy.

Usefulness of a newly designed laser-cut metal stent with an anchoring hook and thin delivery system for EUS-guided hepaticogastrostomy in experimental settings (with video)

BACKGROUND AND AIMS

EUS-guided hepaticogastrostomy (EUS-HGS) is associated with high rates of adverse events. The present study evaluated the feasibility of a newly designed stent equipped with a dilatation and antimigration system for EUS-HGS in phantom and animal models.

METHODS

The newly designed stent was a partially covered laser-cut stent with antimigration anchoring hooks and a thin tapered tip (7.2F). The feasibility of these stents for biliary obstruction was compared with that of conventional stents. Evaluated outcomes were resistance force to migration in phantom and ex vivo models, rates of technical success and adverse events, and histology in an in vivo model.

RESULTS

The resistance forces on the distal (3.59 vs 1.73 N and 6.21 vs 1.74 N) and proximal (3.58 vs 1.5 N and 5.97 vs 1.67 N) sides in phantom and ex vivo models were significantly higher for hook stents than for conventional stents. Although EUS-HGS was successfully performed in all cases with both stents (100% [10/10] vs 100% [8/8]), the success rate of EUS-HGS without using a fistulous tract dilation device was significantly higher with hook stents (100% [10/10]) than with conventional stents (13% [1/8]). No adverse events occurred with either stent. Pathologic examination showed adhesion between the stomach and liver.

CONCLUSIONS

The strong resistance to migration and the absence of the dilation step are important advantages of newly designed hook stents. These stents may therefore be feasible and safe for EUS-HGS.

[Palliative endoscopy]

Endoscopy is the leading method in the diagnostics of gastrointestinal malignancies. With the increasing incidences of various tumor entities, a palliative treatment situation is already present in many patients despite an increasing number of screening strategies. Palliative endoscopy can make an essential contribution to alleviation of tumor-related symptoms, such as dysphagia, malnutrition, cholestasis, ileus and pain. Various approaches can be offered to safeguard the nutrition, e.g. percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ), for maintenance of the gastrointestinal passage (stents) and secretion drainage or to drain congested hollow organs. Furthermore, in cases of inaccessibility or impassability of stenoses due to tumors, endosonographically assisted punctures offer the possibility to guarantee new drainage options or continuities by stent placement. In all interventions possible contraindications and complications must be taken into account.

What You Need to Know Before Performing Endoscopic Ultrasound-guided Hepaticogastrostomy

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment modality for bile duct obstruction. When ERCP is unsuccessful, percutaneous transhepatic biliary drainage can be an alternative method. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a treatment option for biliary obstruction, especially after ERCP failure. EUS-BD offers transluminal intrahepatic and extrahepatic drainage through a transgastric and transduodenal approach. EUS-guided hepaticogastrostomy (EUS-HGS) is an excellent choice for patients with hilar strictures or those with a surgically altered anatomy. The optimal steps in EUS-HGS are case selection, bile duct visualization, puncture-site selection, wire insertion and manipulation, tract dilation, and stent placement. Caution should be taken at each step to prevent complications. Dedicated devices for EUS-HGS have been developed to improve the technical success rate and reduce complications. This technical review focuses on the essential practical points at each step of EUS-HGS.

Radiologic Assessment for Endoscopic US-guided Biliary Drainage

Endoscopic US-guided biliary drainage (BD) is performed for various types of biliary obstruction and is mainly indicated for unsuccessful conventional transpapillary endoscopic retrograde cholangiodrainage. In endoscopic US BD, an extra-anatomic drainage route between the gastrointestinal (GI) tract and the biliary system is created with a covered metallic stent or plastic stent. Procedural types of endoscopic US BD include hepaticogastrostomy, hepaticojejunostomy (after gastrectomy), choledochoduodenostomy, hepaticoduodenostomy, and endoscopic US-guided gallbladder drainage. The technical and clinical success rates of endoscopic US BD are reported to be 94%-97% and 88%-100%, respectively. CT is crucial both in preprocedural assessment and postprocedural monitoring. CT is used to determine the indications for endoscopic US BD, which include the type of biliary obstruction, collateral vessels in the puncture route, ascites, the volume of the liver segment, the distribution of an intrahepatic tumor, and GI tract patency. After endoscopic US BD, common subclinical findings are a small amount of intraperitoneal gas, localized edematous change in the GI tract, a notch in the placed stent, and localized biliary dilatation caused by stent placement. Stent malfunction after endoscopic US BD is caused by impaction of debris and/or food, stent migration into the GI tract, or tumor overgrowth and/or hyperplasia. Complications that can occur include internal stent migration, intraperitoneal biloma, arterial bleeding or pseudoaneurysm, perforation of the GI tract, and portobiliary fistula. The incidence of clinical endoscopic US BD-related complications is 11%-23%. ^©RSNA, 2020.

Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018

Endoscopic ultrasound/ultrasonography‐guided biliary drainage (EUS‐BD) is a relatively new modality for biliary drainage after failed or difficult transpapillary biliary cannulation. Despite its clinical utility, EUS‐BD can be complicated by severe adverse events such as bleeding, perforation, and peritonitis. The aim of this paper is to provide practice guidelines for safe performance of EUS‐BD as well as safe introduction of the procedure to non‐expert centers. The guidelines comprised patient–intervention–comparison–outcome‐formatted clinical questions (CQs) and questions (Qs), which are background statements to facilitate understanding of the CQs. A literature search was performed using the PubMed and Cochrane Library databases. Statement, evidence level, and strength of recommendation were created according to the GRADE system. Four committees were organized: guideline creation, expert panelist, evaluation, and external evaluation committees. We developed 13 CQs (methods, device selection, supportive treatment, management of adverse events, education and ethics) and six Qs (definition, indication, outcomes and adverse events) with statements, evidence levels, and strengths of recommendation. The guidelines explain the technical aspects, management of adverse events, and ethics of EUS‐BD and its introduction to non‐expert institutions.

Clinical Impact of the Intra-scope Channel Stent Release Technique in Preventing Stent Migration During EUS-Guided Hepaticogastrostomy

BACKGROUNDS

Stent migration following endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) may sometimes be fatal because there are no adhesions between the biliary tract and stomach. To prevent stent migration and minimize the stent length in the abdominal cavity, we recently performed EUS-HGS using the technique of releasing the stent within the scope channel.

AIMS

To examine the technical feasibility of the intra-scope channel stent release technique.

METHODS

Forty-one consecutive patients who underwent EUS-HGS were enrolled. Between October 2015 and December 2015, EUS-HGS was performed using the extra-scope channel release technique, while the intra-scope channel release technique was performed between January 2016 and March 2016.

RESULTS

The distance between the hepatic parenchyma and the stomach wall after EUS-HGS in the intra-scope channel stent release group was significantly shorter than that in the extra-scope channel release group (0.66 ± 1.25 vs 2.52 ± 0.97, P < 0.05). Adverse events, such as biloma or stent migration, were seen in only the extra-scope channel release group.

CONCLUSION

In conclusion, although additional cases and randomized controlled studies using metal stents of various lengths are needed, our technique is likely to be clinically useful for the prevention of early and late stent migration.

Efficacy of the 6-mm fully covered self-expandable metal stent during endoscopic ultrasound-guided hepaticogastrostomy as a primary biliary drainage for the cases estimated difficult endoscopic retrograde cholangiopancreatography: A prospective clinical study

BACKGROUND AND AIM

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is performed as an alternative to the percutaneous or surgical approach. Despite high success rates, the adverse events rate is high. Recently, we used 6-mm fully covered self-expandable metal stents to prevent adverse events and allow easy re-intervention. The purposes were to evaluate the safety, feasibility, and clinical efficacy.

METHODS

A prospective study to confirm the safety of EUS-HGS was carried out in six patients, followed by a trial to evaluate the feasibility and efficacy of EUS-HGS in approximately 12 additional patients. We permitted a total of 18 to 20 patients in consideration of possibility such as the deviation after providing informed consent.

RESULTS

Twenty patients underwent EUS-HGS. No treatment-related adverse events described in the safety assessment criteria were seen. The technical and clinical success rates were 100% and 95%. The adverse event rate was 15%. Focal cholangitis was seen in two patients and fever in one patient. All cases were treated conservatively. Stent dysfunction was seen in 10 patients. The causes of stent dysfunction were biliary sludge (n = 6) and stent dislocation (n = 4). In nine cases, a new stent was easily inserted. Percutaneous drainage was selected in only one patient because of worsening general condition.

CONCLUSIONS

The 6-mm fully covered self-expandable metal stent is safe and effective, especially for avoiding serious adverse events and allowing easy re-intervention. (UMIN000006785).

EUS-Guided Transluminal Interventions

The role of endoscopic ultrasound (EUS) has transitioned from a diagnostic to a therapeutic one over the past 40 years. With the advent of curvilinear array echoendoscopes in the 1990s with an accessory channel, multiple tools and devices have been developed and used for a variety of transluminal interventions. EUS provides a viable option and is becoming the procedure of choice for many interventions, including bile and pancreatic duct drainage, guiding angiotherapy, pancreatic fluid collection management, gallbladder drainage, and creating a gastrojejunostomy. Although reports demonstrate the technical success of these interventions, there is tremendous study heterogeneity and a relative lack of controlled randomized trials, which may limit our understanding of their role and utility. Furthermore, adverse events are relatively common and occasionally severe. Despite the limitations, available data strongly indicate the efficacy of EUS interventions when performed by well-trained endosonographers in carefully selected patients and managed in a multidisciplinary setting.

Successful replacement of a metallic hepaticogastrostomy stent dislocated during endoscopic retrograde cholangiography

In the present case with lower bile duct cancer, an endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was placed because of repeated obstructions of biliary metallic stent. However, when the HGS was occluded, transpapillary duodenoscopic procedure was again required. During this transpapillary procedure, including biliary balloon cleaning and metallic stent deployment, the HGS stent was dislocated into the stomach. Fortunately, due to the complete fistulization, no bile peritonitis was recognized and an HGS stent could be replaced from the gastric wall three days later. Current case report alarms a risk of HGS stent dislocation when conducting endoscopic retrograde cholangiopancreatography (ERCP)-associated procedures after the placement of an HGS stent.

Endoscopic ultrasound-guided choledochoduodenostomy using partially-covered self-expandable metal stent in patients with malignant distal biliary obstruction and unsuccessful ERCP

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is an alternative to percutaneous transhepatic biliary drainage (PTBD) for patients with malignant distal biliary obstruction in whom ERCP has failed. We studied technical success, clinical success, stent patency rate and occurrence of adverse events in patients undergoing EUS-CDS with partially-covered self-expanding metal stent (PCSEMS).

PATIENTS AND METHODS

Medical records of consecutive patients with unresectable malignant distal biliary obstruction requiring biliary drainage who underwent EUS-CDS because of failure of attempt at ERCP were reviewed. EUS-CDS was done using 6-cm, PCSEMS (Wallflex, Boston Scientific). Technical success, clinical success (more than 50 % reduction in total bilirubin at 2 weeks post-procedure), stent patency rate and adverse events (AEs) were assessed. Patients were followed up for 3 months post-procedure.

RESULTS

Between January 2015 and December 2016, 30 patients underwent EUS-CDS, including 20 (67 %) with failed biliary cannulation and 10 (33 %) with duodenal stenosis. Technical success was achieved in 28 patients, all of whom also had clinical success. Median total serum bilirubin decreased from 20 mg/dL to 5 mg/dL at 2 weeks post-procedure. Three patients (10 %) had adverse events (bile leak, hemobilia, stent block in one patient each; no stent migration); none of these adverse events was major and all were managed successfully. There were no procedure-related deaths. Five patients died of disease progression in the 3-month period post-procedure, and the 3-month dysfunction-free stent patency rate was 83 %.

CONCLUSION

EUS-CDS with a PCSEMS has a high technical and clinical success. Adverse events were infrequent, minor and could be managed easily.

The intra-conduit release method is useful for avoiding migration of metallic stents during EUS-guided hepaticogastrostomy (with video)

PURPOSE

Although EUS-guided hepaticogastrostomy (EUS-HGS) with a covered self-expandable metal stent (SEMS) is a useful procedure, it is associated with severe adverse events, including stent migration. We, therefore, developed an intra-conduit release method, and investigated whether the technique yields a safer and more stable procedure.

METHODS

The intra-conduit release method is a procedure to release the SEMS in the working channel conduit of the scope for anchoring between the liver and stomach to avoid stent migration. Forty-three patients who underwent EUS-HGS at two high-volume centers in Japan were enrolled in this retrospective study, and the safety and usefulness of this method were evaluated retrospectively.

RESULTS

The intra-conduit release method was applied in 36 cases. The technical success rate of EUS-HGS with the intra-conduit release method was significantly higher in comparison with the conventional method. Additionally, the rate of early adverse events was significantly lower than that for the conventional method.

CONCLUSION

The intra-conduit release method during EUS-HGS is useful for a stable procedure that avoids early adverse events.

Long-term outcomes of a newly developed hybrid metal stent for EUS-guided biliary drainage (with videos)

BACKGROUND AND AIMS

Although fully covered self-expandable metal stents (FCSEMSs) have been commonly used for EUS-guided biliary drainage (EUS-BD), FCSEMS migration is a main limitation of this procedure. In the present study we evaluated the technical and clinical success rates, adverse events, and long-term outcomes of a newly developed hybrid stent that has been customized for EUS-BD.

METHODS

From September 2011 to May 2015, 54 consecutive patients with biliary obstruction were enrolled in this prospective, observational study. These patients were candidates for alternative BD techniques because of failed ERCP. The hybrid metal stent used for EUS-BD in this study was partially covered, had anchoring flaps, and is commercially available in Korea.

RESULTS

EUS-guided hepaticogastrostomy (EUS-HGS) was performed in 21 patients and EUS-guided choledochoduodenostomy (EUS-CDS) in 33 patients. The technical and clinical success rates of EUS-BD were 100% (54/54) and 94.4% (51/54), respectively. Immediate adverse events developed after EUS-BD in 9 patients (16.6%; cholangitis in 3, bleeding in 2, self-limited pneumoperitoneum in 3, and abdominal pain in 1). Proximal or distal stent migration was not observed during the follow-up period (median, 148.5 days; IQR, 79.7-244), and the mean stent patency duration was 166.3 days and 329.1 days in the EUS-HGS and EUS-CDS groups, respectively.

CONCLUSIONS

EUS-BD with the hybrid metal stent is technically feasible and can effectively treat biliary obstruction after failed ERCP. EUS-BD with the hybrid metal stent can reduce stent-related adverse events, especially stent migration.

Optimal biliary access point and learning curve for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting

BACKGROUND

Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) with transmural stenting has increased for biliary decompression in patients with an inaccessible papilla, the optimal biliary access point and the learning curve of EUS-HGS have not been studied. We evaluated the optimal biliary access point and learning curve for technically successful EUS-HGS.

METHODS

129 consecutive patients (male n = 81, 62.3%; malignant n = 113, 87.6%) who underwent EUS-HGS due to an inaccessible papilla were enrolled. EUS finding and procedure times according to each needle puncture attempt in EUS-HGS were prospectively measured. Learning curves of EUS-HGS were calculated for two main outcome measurements (procedure time and adverse events) by using the moving average method and cumulative sum (CUSUM) analysis, respectively.

RESULTS

A total of 174 EUS-HGS attempts were performed in 129 patients. The mean number of needle punctures was 1.35 ± 0.57. Using the logistic regression model, bile duct diameter of the puncture site ⩽ 5 mm [odds ratio (OR) 3.7, 95% confidence interval (CI): 1.71-8.1, p < 0.01] and hepatic portion length [linear distance from the mural wall to the punctured bile duct wall on EUS; mean hepatic portion length was 27 mm (range 10-47 mm)] > 3 cm (OR 5.7, 95% CI: 2.7-12, p < 0.01) were associated with low technical success. Procedure time and adverse events were shorter after 24 cases, and stabilized at 33 cases of EUS-HGS, respectively.

CONCLUSIONS

Our data suggest that a bile duct diameter > 5 mm and hepatic portion length 1 cm to ⩽ 3 cm on EUS may be suitable for successful EUS-HGS. In our learning curve analysis, over 33 cases might be required to achieve the plateau phase for successful EUS-HGS.

Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review

BACKGROUND AND AIMS

EUS-guided biliary drainage (EUS-BD) has emerged as an alternative procedure after failed ERCP. However, limited data on the efficacy and safety of EUS-BD are available. Therefore, a systematic review was conducted to evaluate the efficacy and safety of EUS-BD and to evaluate transduodenal (TD) and transgastric (TG) approaches.

METHODS

PubMed and EMBASE were searched to identify relevant studies published in the English language for inclusion in this systematic review and meta-analysis. Data from eligible studies were combined to calculate the cumulative technical success rate (TSR), functional success rate (FSR), and adverse-event rate of EUS-BD and the pooled odds ratio of TSR, FSR, and adverse-event rate of the TD approach when compared with the TG approach.

RESULTS

Forty-two studies with 1192 patients were included in this study, and the cumulative TSR, FSR, and adverse-event rate were 94.71%, 91.66%, and 23.32%, respectively. The common adverse events associated with EUS-BD were bleeding (4.03%), bile leakage (4.03%), pneumoperitoneum (3.02%), stent migration (2.68%), cholangitis (2.43%), abdominal pain (1.51%), and peritonitis (1.26%). Ten studies were included in the meta-analysis for comparative evaluation of TD and TG approaches for EUS-BD. Compared with the TG approach, the pooled odds ratio of the TSR, FSR, and adverse-event rate of the TD approach were 1.36 (95% CI, .66-2.81; P > .05), .84 (95% CI, .50-1.42; P > .05), and .61 (95% CI, .36-1.03; P > .05), respectively, which indicated no significant difference in the TSR, FSR, and adverse-event rate between the 2 groups.

CONCLUSIONS

Although it is associated with significant morbidity, EUS-BD is an effective alternative procedure for relieving biliary obstruction. There was no significant difference between the TD and TG approaches for EUS-BD.

Technical tips for endoscopic ultrasound-guided hepaticogastrostomy

Interventional procedures using endoscopic ultrasound (EUS) have recently been developed. For biliary drainage, EUS-guided trans-luminal drainage has been reported. In this procedure, the transduodenal approach for extrahepatic bile ducts is called EUS-guided choledochoduodenostomy, and the transgastric approach for intrahepatic bile ducts is called EUS-guided hepaticogastrostomy (EUS-HGS). These procedures have several effects, such as internal drainage and avoiding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, and they are indicated for an inaccessible ampulla of Vater due to duodenal obstruction or surgical anatomy. EUS-HGS has particularly wide indications and clinical impact as an alternative biliary drainage method. In this procedure, it is necessary to dilate the fistula, and several devices and approaches have been reported. Stent selection is also important. In previous reports, the overall technical success rate was 82% (221/270), the clinical success rate was 97% (218/225), and the overall adverse event rate for EUS-HGS was 23% (62/270). Adverse events of EUS-biliary drainage are still high compared with ERCP or PTCD. EUS-HGS should continue to be performed by experienced endoscopists who can use various strategies when adverse events occur.

Endoscopic ultrasonography: Transition towards the future of gastro-intestinal diseases

Endoscopic ultrasonography (EUS) is a technique with an established role in the diagnosis and staging of gastro-intestinal tumors. In recent years, the spread of new devices dedicated to tissue sampling has improved the diagnostic accuracy of EUS fine-needle aspiration. The development of EUS-guided drainage of the bilio-pancreatic region and abdominal fluid collections has allowed EUS to evolve into an interventional tool that can replace more invasive procedures. Emerging techniques applying EUS in pancreatic cancer treatment and in celiac neurolysis have been described. Recently, confocal laser endomicroscopy has been applied to EUS as a promising technique for the in vivo histological diagnosis of gastro-intestinal, bilio-pancreatic and lymph node lesions. In this state-of-the-art review, we report the most recent data from the literature regarding EUS devices, interventional EUS, EUS-guided confocal laser endomicroscopy and EUS pancreatic cancer treatment, and we also provide an overview of their principles, clinical applications and limitations.

Clinical Outcome of Endoscopic Ultrasound-Guided Liver Abscess Drainage Using Self-Expandable Covered Metallic Stent (with Video)

BACKGROUND

Percutaneous drainage (PCD) is now the first-line drainage method for liver abscess because of its minimal invasiveness and high technical success rate. However, this procedure has several disadvantages, such as extra-drainage and self-tube removal. Recently, EUS-guided liver abscess drainage (EUS-AD) has been developed. However, only a few reports of EUS-AD have been reported. In addition, the clinical benefits of PCD and EUS-AD have not been reported.

AIMS

In the present study, the safety and feasibility of EUS-AD using fully covered SEMS (FCSEMS) and the clinical outcomes of EUS-AD and PCD were examined retrospectively.

METHODS

Twenty-seven consecutive patients who underwent PCD or EUS-AD between April 2012 and April 2015 were included in this study. EUS-AD was performed using FCSEMS. In addition, to prevent stent migration, 7-Fr pig tail plastic stent was placed within FCSEMS.

RESULTS

Technical success was achieved in all patients of both groups. Clinical success was 100 % in the EUS-AD group although it was 89 % in PCD group (P = 034). Three adverse events were seen in the PCD group (self-tube removal n = 1, tube migration n = 2), but no adverse events were seen in the EUS-AD group. The median hospital stay was significantly shorter in the EUS-AD group than in the PCD group (21 vs 41 days, P = 0.03).

CONCLUSION

Because of the short hospital stay, the high clinical success rate, and the low adverse event rate compared to PCD, EUS-AD has potential as a first-line treatment for liver abscess.

Stent length is impact factor associated with stent patency in endoscopic ultrasound-guided hepaticogastrostomy

BACKGROUND AND STUDY AIM

Despite high technical and functional success rates with endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), rates of adverse events have also been high. No reports have focused on EUS-HGS alone with a large sample size about predictors of stent patency. The present study examined predictors of stent patency in patients who underwent EUS-HGS.

PATIENTS AND METHODS

The consecutive 51 patients who underwent EUS-HGS using one metallic stent were retrospectively enrolled in this study. Baseline characteristics, stent length from the hepatic portion and in the luminal portion, kinds of stent dysfunction, and stent patency were reviewed.

RESULTS

Median duration of stent patency was significantly shorter with stent length in the luminal portion <3 cm (52 days) than with ≥3 cm (195 days; P < 0.01). On the other hand, median duration of stent patency did not differ significantly between ≥4 cm (194 days) and <4 cm (127 days; P = 0.1726). Length of stent in the luminal portion ≥3 cm (Hazard ration [HR], 9.242; 95% confidence interval [CI], 3.255-26.244, P < 0.05) and performance of chemotherapy (HR, 3.022; 95% CI, 1.448-6.304, P < 0.05) were also associated with long stent patency on the Cox proportional hazards model.

CONCLUSION

In conclusion, to obtain long-term stent patency, our data suggest that a stent length ≥3 cm in the luminal portion may be suitable for EUS-HGS.

Hepatic applications of endoscopic ultrasound: Current status and future directions

The diagnosis and staging of various gastrointestinal malignancies have been made possible with the use of endoscopic ultrasound, which is a relatively safe procedure. The field of endoscopic ultrasound is fast expanding due to advancements in therapeutic endoscopic ultrasound. Though various studies have established its role in gastrointestinal malignancies and pancreatic conditions, its potential in the field of hepatic lesions still remains vastly untapped. In this paper the authors attempt to review important and landmark trials, case series and case studies involving hepatic applications of endoscopic ultrasound, thus not only providing an overview of utilization of endoscopic ultrasound in various liver conditions but also speculating its future role.

Endoscopic Ultrasound-Assisted Pancreaticobiliary Access

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary approach to drain an obstructed pancreatic or biliary duct. Failed biliary drainage is traditionally referred for percutaneous transhepatic biliary drainage or surgical bypass, which carry significantly higher morbidity and mortality rates compared with ERCP and transpapillary drainage. Endoscopic ultrasound provides a real-time imaging platform to access and deliver therapy to organs and tissues outside of the bowel lumen. The bile and pancreatic ducts can be directly accessed from the stomach and duodenum, offering an alternative to ERCP when this fails or is not feasible.

Does endoscopic ultrasound-guided biliary drainage really have clinical impact?

The well established, gold standard method for treatment of obstructive jaundice involves biliary drainage under endoscopic retrograde cholangiopancreatography (ERCP) performed by pancreatobiliary endoscopists. Recently, interventions using endoscopic ultrasound (EUS) have been developed not only for obtaining cytological and histological diagnosis, but also for biliary drainage as alternative method. EUS-guided biliary drainage (EUS-BD) was first reported by Giovannini et al. EUS-BD broadly includes EUS-guided rendezvous technique, EUS-guided choledochoduodenostomy, and EUS-guided hepaticogastrostomy. More recently, EUS-guided antegrade stenting and EUS-guided gallbladder drainage have also been reported. many case reports, series, and retrospective studies on EUS-BD have been reported. However, because prospective studies and comparisons between the different biliary drainage methods have not been reported, the technical success, functional success, adverse events, and stent patency with long-term follow up of EUS-BD are still unclear. Therefore, prospective, randomized controlled studies addressing these issues are needed. Despite this, EUS-BD undoubtedly is clinically useful as an alternative biliary drainage method. EUS-BD has the potential to be a first-line biliary drainage method instead of ERCP if results of clinical trials are favorable and the technique is simplified.