EUS-Guided Biliary Drainage. Gastroenterol Res Pract. 2012;2012:348719. [PMID: 21860619 PMCID: PMC3157156 DOI: 10.1155/2012/348719]

Safety and effectiveness of consecutive 191 endoscopic ultrasonography-guided biliary drainage procedures: a single-center experience

<b>Introduction:</b> The development of endoscopic ultrasonography (EUS) has enabled extra-anatomical transmural access to the bile ducts, thus making it possible to perform endoscopic biliary anastomoses with the gastrointestinal (GI) tract and obtain extra-anatomical transpapillary access. EUS provides an alternative to the existing methods of biliary drainage (BD) for cases in which endoscopic retrograde cholangiopancreatography (ERCP) is ineffective.<b>Aim:</b> This study aimed to evaluate the efficacy and safety of extraanatomical endoscopic biliary access methods for the treatment of benign and malignant biliary strictures.<b>Material and methods:</b> This retrospective analysis included treatment results of all patients with obstructive jaundice and biliary strictures who were treated endoscopically in our department between 2016 and 2023. The study group comprised patients in whom EUS-guided transmural access was used during ERCP because of biliary strictures and the lack of transpapillary access.<b>Results:</b> Twenty-eight patients (14.66%) underwent endoscopic transpapillary biliary stenting via a transmural approach under EUS guidance. The remaining 163 patients (85.34%) underwent extraanatomical transmural biliodigestive anastomosis. Technical success was achieved in 186 of 191 (97.38%) patients. Clinical success was achieved in 170 of 191 (89.01%) patients. Complications were reported for 32 of 191 (16.75%) patients, including fatal complications for 6 of 191 (3.14%) patients.<b>Conclusions:</b> Advanced endoscopic techniques involving EUS-guided transmural access are effective and safe for biliary strictures. They provide an alternative to other drainage techniques when ERCP is ineffective and improve the quality of life of patients undergoing palliative treatment for biliary strictures with unresectable cancer of the biliopancreatic area.

The Role of Endoscopic Ultrasound-guided Transmural Approach in the Management of Biliary Obstructions

BACKGROUND

Transpapillary biliary drainage in endoscopic retrograde cholangiopancreatography (ERCP) is an established method for treatment of patients with benign and malignant biliary obstruction. However, attempts to gain access to the biliary tract through the major duodenal papilla during ERCP have been unsuccessful in some patients. This study aims to determine the role of endoscopic ultrasonography (EUS)-guided transmural approach in biliary endotherapy in case of failed ERCP.

MATERIALS AND METHODS

A prospective analysis of the treatment outcomes of all 896 patients with obstructive jaundice secondary to biliary obstruction, who underwent endoscopic treatment in the years 2016-2021 at our institution.

RESULTS

Effective drainage of bile ducts through the major duodenal papilla during ERCP was achieved in 772/896 (86.16%) patients with biliary obstruction. In 124/896 (13.84%) patients [92 males, 32 females; mean age 63.52 (46 to 89) y] ERCP failed and EUS-guided transmural approach was performed. Benign biliary obstruction was identified in 17/124 (13.71%) patients; the remaining 107/124 (86.29%) were diagnosed with malignant biliary obstruction. EUS-guided endoscopic transpapillary biliary tract stenting with transmural access was performed in 21/124 (16.94%) patients; the remaining 103/124 (83.06%) required extra-anatomic transmural anastomosis of the bile ducts to the gastrointestinal tract. Technical success was achieved in 121/124 (97.58%) patients, while clinical success was achieved in 112/124 (90.32%). Complications were reported in 15/124 (12.1%) patients; with early complications in 12 and late complications in 3.

CONCLUSIONS

Various methods of EUS-guided transmural access to bile ducts improves endotherapy outcomes of patients with biliary obstruction. Endoscopic transmural access is highly effective and associated with an acceptable number of complications.

Endoscopic ultrasound-guided biliary drainage-current status and future perspectives

Endoscopic retrograde cholangiopancreatography (ERCP) with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction. ERCP could fail in cases of duodenal obstruction, duodenal diverticulum, ampullary neoplastic infiltration or surgically altered anatomy. In these cases percutaneous biliary drainage (PTBD) is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices. A large amount of data is already collected that proves its efficacy, safety and ability to replace PTBD in cases of ERCP failure. It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future. Several EUS-BD techniques are developed EUS-guided transmural stenting, antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy. EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure. The lack of training, absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure, which is related to life-threatening adverse events. Developing training models, dedicated devices and guidelines hopefully will make EUS-BD easier, safer and well accepted in the future. This paper focuses on the technical aspects of the different EUS-BD procedures, available literature data, advantages, negative aspects and the future perspectives of these modalities.

Newly Designed Laser-Cut Metal Stent with an Anchoring Hook and Thin Delivery System for Endoscopic Ultrasound–Guided Hepaticogastrostomy: Is It a Dream Stent?

Endoscopic ultrasound–guided hepaticogastrostomy (EUS-HGS) involves creation of an anastomosis between two intra-abdominal mobile organs, namely, liver and the stomach, with no intervening stricture. Therefore, the risk of stent migration in EUS-HGS is very high and the stent migration can lead on to severe life-threatening complications like biliary peritonitis. During last few years, there have been increased efforts to design a safe and effective stent for EUS-HGS that obviates the risk of stent migration and can also be inserted quickly, preferably, in a single-step procedure. In this news and views, we discuss an experimental study from Japan that has evaluated a new partially covered self-expandable laser cut metal stent with a thin delivery system (7.2 F) and antimigration anchoring hooks for single-step EUS-HGS in phantom and animal models.

Outcomes and limitations of endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction

Background

Transpapillary biliary drainage in ERCP is an established method for symptomatic treatment of patients with unresectable malignant biliary obstruction. Percutaneous transhepatic biliary drainage frequently remains the treatment of choice when the transpapillary approach proves ineffective. Recently, EUS-guided extra-anatomical anastomoses of bile ducts to the gastrointestinal tract have been reported as an alternative to percutaneous biliary drainage. To assess the usefulness of extra-anatomical intrahepatic biliary duct anastomoses to the gastrointestinal tract as endotherapy for unresectable malignant biliary obstruction and to determine factors affecting the efficacy of treatment.

Methods

A prospective analysis of the treatment results of all patients with unresectable biliary obstruction treated with EUS-guided hepaticogastrostomy at our institution in the years 2016–2019.

Results

Transmural intrahepatic biliary drainage (EUS-guided hepaticogastrostomy) was performed due to the ineffectiveness of ERCP in 53 patients (38 males, 15 females; mean age 74.66 [56–89] years) with unresectable biliary obstruction. Technical success of EUS-guided hepaticogastrostomy was achieved in 52/53 (98.11%) patients. Complications of endoscopic treatment were observed in 10/53 (18.87%) patients. Clinical success of EUS-guided hepaticogastrostomy was achieved in 46/53 (86.79%) patients. Bismuth type II–IV cholangiocarcinoma, hepatic metastases, ascites, suppurative cholangitis, and high blood bilirubin levels exceeding 30 mg/dL were independent factors for increased complications and inefficacy of EUS-guided hepaticogastrostomy.

Conclusions

In the event of transpapillary biliary drainage proving ineffective, extra-anatomical anastomoses of intrahepatic bile ducts to the gastrointestinal tract provide an effective method for the treatment of patients with malignant biliary obstruction.

The new era of endoscopic ultrasound in biliary disorders

Biliary obstruction is one of challenging biliary disorders in gastroenterology field, where this long-standing condition can also lead to portal hypertension and multi-disciplinary teamwork is usually needed to manage this problem. Biliary drainage is the primary management to prevent prolonged cholestasis. Biliary system with its thin-walled and tubular structure sometimes makes the diagnosis and therapeutic not easy to approach. Over the past 3 decades, numerous new and modern diagnostic and therapeutic modalities have been developed to manage the complex biliary problems. It is well known that endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and surgical procedure are common procedures in managing biliary disorders. However, surgical therapy and ERCP are not always easy to perform due to several contraindications. Because of difficulty in performing these procedures or unavailability of these procedures in the facility, PTBD, as the primary non-surgical procedure of choice, has been popular due to its easy technique. Endoscopic ultrasound (EUS) has evolved significantly not only as a diagnostic tool for identification and staging, but also for interventional approaches, especially in management of biliary malignancy. Recently, EUS-guided biliary drainage (EUS-BD) and EUS-guided gallbladder drainage (EUS-GBD) are developed for managing biliary disorders. Whether EUS can be useful for managing biliary obstruction as a primary procedure is still controversial. Hence, a large number of further studies are required to validate.

Efficacy and Safety of EUS-Guided Choledochoduodenostomy Using Electrocautery-Enhanced Lumen-Apposing Metal Stents (ECE-LAMS) in the Treatment of Biliary Obstruction: A Systematic Review and Meta-Analysis

Background. Electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) have been newly developed to perform EUS-guided choledochoduodenostomy (EUS-CDS), but its benefits and harms remain obscure. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of EUS-CDS using ECE-LAMS. Method. In the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we searched PubMed, Embase, and Scopus databases through January 1, 2001, and April 27, 2020. The primary outcomes of the pooled analysis were to determine the technical success, clinical success, and overall adverse events rates. The secondary outcomes were pooled rates of short-term and long-term adverse events. Results. Six studies with 270 patients were finally included in this meta-analysis. The pooled rates of technical, clinical success, and adverse events were 95.1% (95% CI = 90.6–97.5%, I2 = 25%), 93.3% (95% CI = 87.4–96.5%, I2 = 28%), and 15.3% (95% CI = 10.6–21.6%, I2 = 13%), respectively. The pooled rates of short-term and long-term adverse events were 3.6% (95% CI = 1.3–9.6%, I2 = 0%) and 11.3% (95% CI = 7.6–16.5%, I2 = 0%), respectively. Conclusion. EUS-CDS using ECE-LAMS provides favorable outcomes in patients with biliary obstruction. It has been associated with a higher success rate and a lower rate of adverse events when compared with the biliary drainage approaches previously used. Large and randomized controlled observational studies are required to further refine the findings in the present analysis.

Biliary Drainage Before and After Liver Resection for Perihilar Cholangiocarcinoma

Perihilar cholangiocarcinoma (PHC) is a rare tumor that requires surgical resection for a potential cure. The role of preoperative biliary drainage has long been debated, given its treatment of biliary sepsis and decompression of the future liver remnant (FLR), but high procedure-specific morbidity. The indications, methods, and outcomes for preoperative biliary drainage are discussed to serve as a guide for perioperative management of patients with resectable PHC. Multiple studies from the literature related to perihilar cholangiocarcinoma, biliary drainage, and management of the FLR were reviewed. Commonly employed preoperative biliary drainage includes endoscopic biliary stenting and percutaneous transhepatic biliary drainage. Drainage of the FLR remains controversial, with most experts recommending drainage of the only in patients with an FLR <50%. Biliary drainage for resectable PHC requires a patient-specific approach with careful determination of the FLR and balancing of potential morbidity with the benefits of drainage.

Endoscopic Ultrasound in Pediatric Patients With Pancreatobiliary Disease

BACKGROUND

Endoscopic ultrasound (EUS) is one of the greatest advances of the last few decades for the diagnostic and therapeutic approach of gastrointestinal diseases in adults. However, there are limitations to the application of the procedure in the pediatric population. The aim of this study was to describe the diagnostic yield and therapeutic role of EUS in pediatric patients with pancreatobiliary disease.

MATERIALS AND METHODS

A retrospective study was performed on a prospective database of pediatric patients who underwent diagnostic and therapeutic endosonographic procedures. All patients seen in a 12-year period were included.

RESULTS

A total of 54 patients were included, including 32 (59.3%) female individuals, with an average age of 16 (9 to 17) years. EUS was abnormal in 46 (85%) patients. Of the abnormal procedures, 4 (7.4%) corresponded to therapeutic ones. The main indication of the study was recurrent acute pancreatitis in 29 (54%). The main endosonographic findings were microlithiasis in 14 (25.9%), chronic pancreatitis in 9 (16.7%), and pancreatic tumors in 6 (11.1%) patients. Follow-up was performed in 31 (57.4%) patients, 19/31 patients underwent surgery, and 4/31 patients had endoscopic retrograde cholangiopancreatography. The median follow-up was 910 (2 to 3916) days. In 100% of the patients with follow-up, the initial diagnosis of EUS was confirmed.

CONCLUSION

EUS is a useful and safe tool in the pediatric population with pancreatobiliary diseases.

[Relief of Obstruction in the Management of Pancreatic Cancer]

Pancreatic cancer is a major cause of cancer-related mortality and morbidity, and its incidence is increasing as the population is aging. On the other hand, significant improvement in the prognosis has not occurred. The absence of early diagnosis means that many patients are diagnosed only when they develop symptoms, such as jaundice, due to a biliary obstruction. The role of endoscopy in multidisciplinary care for patients with pancreatic cancer continues to evolve. Controversy remains regarding the best preoperative biliary drainage in patients with surgically resectable pancreatic head cancer. In general, patients undergoing a surgical resection usually do not require preoperative biliary drainage unless they have cholangitis or receive neoadjuvant chemotherapy. If biliary drainage is performed prior to surgery, the patient's condition and a multidisciplinary approach should be considered. With the increasing life expectancy of patients with pancreatic cancer, the need for more long-time biliary drainage or pre-operative biliary drainage is also increasing. Strong evidence of endoscopic retrograde cholangiopancreatography (ERCP) as a first-line and essential treatment for biliary decompression has been provided. On the other hand, the use of endoscopic ultrasound-guided biliary drainage as well as percutaneous biliary drainage has been also recommended. During ERCP, self-expandable metal stent could be recommended instead of a plastic stent for the purpose of long stent patency and minimizing stent-induced complications. In this review, several points of view regarding the relief of obstruction in patients with pancreatic cancer, and optimal techniques are being discussed.

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).

A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction

Background and Objectives:

EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed.

Methods:

This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD.

Results:

Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the First choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended.

Conclusion:

This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition.

Endoscopic ultrasound-guided hepaticogastrostomy versus percutaneous transhepatic drainage for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography: a retrospective expertise-based study from two centers

BACKGROUND

Percutaneous transhepatic biliary drainage (PTBD) is widely performed as a salvage procedure in patients with unresectable malignant obstruction of the common bile duct (CBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) or in case of surgically altered anatomy. Endoscopic ultrasound-guided hepaticogastrostomy (EU-HGS) is a more recently introduced alternative to relieve malignant obstructive jaundice. The aim of this prospective observational study was to compare the outcome, efficacy and adverse events of EU-HGS and PTBD.

METHODS

From April 2012 to August 2015, consecutive patients with malignant CBD obstruction who underwent EU-HGS or PTBD in two tertiary-care referral centers were included. The primary endpoint was the clinical success rate. Secondary endpoints were technical success, overall survival, procedure-related adverse events, incidence of adverse events, and reintervention rate.

RESULTS

A total of 51 patients (EU-HGS, n = 31; PTBD, n = 20) were included. Median survival was 71 days (range 25-75th percentile; 30-95) for the EU-HGS group and 78 days (range 25-75th percentile; 42-108) for the PTBD group (p = 0.99). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 (86%) of 31 patients in the EU-HGS group and in 15 (83%) of 20 patients in the PTBD group (p = 0.88). There was no difference in adverse events rates between the two groups (EU-HGS: 16%; PTBD: 10%) (p = 0.69). Four deaths within 1 month (two hemorrhagic and two septic) were considered procedure related (two in the EU-HGS group and two in the PTBD group). Overall reintervention rate was significantly lower after EU-HGS (n = 2) than after PTBD (n = 21) (p = 0.0001). Length of hospital stay was shorter after EU-HGS (8 days versus 15 days; p = 0.002).

CONCLUSIONS

EU-HGS can be an effective and safe mini invasive-procedure alternative to PTBD, with similar success and adverse-event rates, but with lower rates of reintervention and length of hospitalization.

Use of partially covered and uncovered metallic prosthesis for endoscopic ultrasound-guided hepaticogastrostomy: Results of a retrospective monocentric study

Background and Objectives:

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) represents an option to treat obstructive jaundice when endoscopic retrograde cholangiopancreatography (ERCP) fails. The success rate of this procedure has been shown to be very high. Up to now, plastic and self-expandable metallic stents (SEMSs) have been employed, each of them presenting some limitations. The aims of this study were to evaluate the technical and functional success rates of EUS-HGS using a dedicated biliary SEMS with a half-covered part (Giobor^® stent).

Methods:

We retrospectively reviewed data of patients, who underwent EUS-HGS at our center, with at least 6 months of follow-up. Demographic, clinical, and laboratory data were extracted from the patient's charts and electronic records. Technical success rate was defined as the successful passage of the Giobor stent across the stomach, along with the flow of contrast medium and/or bile through the stent. Functional success rate was considered achieved when the decrease of bilirubin value of at least 25% within the 1^st week was obtained. The rate of early and late complications was assessed.

Results:

A total of 41 patients were included (21F/20M, [mean age 66, range 45–85]). Technical success rate was obtained in 37 (90.2%) of patients. Functional success rate, analyzable in 29 patients, occurred in 65%. Between the 37 patients in whom HGS was technically feasible, 13 patients (31.7%) presented an early complication, mostly infective. At 6-month follow-up, 10/37 patients (27.0%) required a new biliary drainage (BD) and 11/37 (29.7%) died because of their disease.

Conclusions:

EUS-HGS using Giobor^® stent is technically feasible, clinical effective, safe, and may be an alternative to percutaneous transhepatic BD in case of ERCP failure for biliary decompression.

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.

Impact of Endoscopic Ultrasound Procedures in Various Pancreatobiliary Disorders in Indonesia Based on a Case Series in a Private Hospital

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is a common technique for assessing the pancreas and the biliary system; however, the potential complications have raised concern among endoscopists and patients. Recently, the need of endoscopic ultrasound (EUS) as an additional tool of assessment before the ERCP procedure has been increasing. The need of EUS in developing countries is still a matter of debate regarding the cost, investment, and training. Here, we report the significant impact of EUS on several unselected interesting cases of pancreatobiliary disorders.

Method

We selected several interesting cases from the patients who underwent EUS at our private hospital in Jakarta, Indonesia. The EUS procedures were performed by one experienced endosonographer and one EUS trainee who are very experienced with transabdominal ultrasound. The equipment was an Olympus JF UCT 180 EUS scope which was connected to an Aloka IPF-1701C ultrasound machine (Tokyo, Japan).

Results

Five interesting cases were included from patients who underwent EUS due to pancreatobiliary disorders. The cases included recurrent pancreatitis due to pancreatic stone at the small branch that obstructed the main pancreatic duct, common bile duct (CBD) stone with insignificant duct dilatation, pancreatic head cancer with total obstruction at the distal CBD and portal vein infiltration, pancreas divisum in a young girl, and distal CBD mass that caused obstructive jaundice.

Conclusions

The EUS procedure has shown a significant impact in managing patients with pancreatobiliary diseases. In most developing countries, EUS needs to be evaluated further regarding the cost, investment, and training.

Feasibility and safety of using Soehendra stent retriever as a new technique for biliary access in endoscopic ultrasound-guided biliary drainage

AIM: To assess the feasibility and safety of the use of soehendra stent retriever as a new technique for biliary access in endoscopic ultrasound-guided biliary drainage.

METHODS: The medical records and endoscopic reports of the patients who underwent endoscopic ultrasound-guided biliary drainage (EUS-BD) owing to failed endoscopic retrograde cholangiopancreatography in our institute between June 2011 and January 2014 were collected and reviewed. All the procedures were performed in the endoscopic suite under intravenous sedation with propofol and full anaesthetic monitoring. Then we used the Soehendra stent retriever as new equipment for neo-tract creation and dilation when performing EUS-BD procedures. The patients were observed in the recovery room for 1-2 h and transferred to the regular ward, patients’ clinical data were reviewed and analysed, clinical outcomes were defined by using several different criteria. Data were analysed by using SPSS 13 and presented as percentages, means, and medians.

RESULTS: A total of 12 patients were enrolled. The most common indications for EUS-BD in this series were failed common bile duct cannulation, duodenal obstruction, failed selective intrahepatic duct cannulation, and surgical altered anatomy for 50%, 25%, 16.7%, and 8.3%, respectively. Seven patients underwent EUS-guided hepaticogastrostomy (58.3%), and 5 underwent EUS-guided choledochoduodenostomy (41.7%). The technical success rate was 100%, while the clinical success rate was 91.7%. Major and minor complications occurred in 16.6% and 33.3% of patients, respectively, but there were no procedure-related death.

CONCLUSION: Soehendra stent retriever could be used as an alternative instrument for biliary access in endoscopic ultrasound guided biliary drainage.

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

BACKGROUND AND STUDY AIM

The present study assesses the feasibility as well as the technical and functional success rates of a novel endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) technique called the locking stent method that uses end-bare covered metallic stents (EBCMS).

METHODS

Twenty consecutive patients who were histologically diagnosed with unresectable cancer complicated with obstructive jaundice underwent EUS-HGS due to failed endoscopic biliary drainage or inaccessible papilla. We retrospectively collected clinical data for these patients including technical and functional success rates and complications.

RESULTS

Seven were treated by EUS-HGS (EUS-HGS group), and 13 were treated using the locking stent EUS-HGS method (LS group). Technical and functional success rates were 100% in both groups. Procedural duration did not significantly differ between the EUS-HGS and LS groups (26.9 ± 9.0 versus 32.3 ± 11.1 min, P = 0.30). Two patients developed complications related to stent migration in the EUS-HGS group. In contrast, although mild post-procedural bile peritonitis required conservative treatment for a few days, none of the stents malfunctioned in the LS group.

CONCLUSION

Our method can safely and effectively prevent stent dysfunction, but validation in a prospective clinical trial is required.

Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy

AIM

To evaluate the success rates, procedural time and adverse event rates of the modified methods in endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS).

METHODS

Twenty-eight patients in a prospective case series who underwent EUS-HGS (phase I). Forty-six patients in a matched case-control study (phase II). The simplified technique for fistula dilation was the primary use of a 4 mm balloon catheter with a stainless steel stylet. The stent deployment was modified by deploying the metal stent inside a bile duct (half of the stent) under EUS and fluoroscopic guidance and gently pulling the echoendoscope after full deployment of the stent inside the echoendoscope channel (remaining portion of the stent) under fluoroscopic guidance. This cohort was compared with a matched historical cohort.

RESULTS

In phase I, the technical and clinical success with the modified method was 96% (27/28) and 89% (24/27 as per-protocol analysis). The overall adverse event rate was 7%. In phase II, there was no difference in technical and clinical success, stent patency and overall adverse events in each group. However, the procedural time (15.3 ± 5.2 min vs 22.3 ± 6.0 min, P < 0.001) and early adverse events (0% vs 26%, P = 0.02) were statistically improved in case cohort compared with control cohort.

CONCLUSION

Compared with the conventional EUS-HGS technique, the procedural time was shorter and early adverse events were less frequent with our simplified and modified technique.

EUS-guided biliary drainage by using a standardized approach for malignant biliary obstruction: rendezvous versus direct transluminal techniques (with videos)

BACKGROUND

EUS-guided biliary drainage (EGBD) can be performed via direct transluminal or rendezvous techniques. It is unknown how both techniques compare in terms of efficacy and adverse events.

OBJECTIVE

To describe outcomes of EGBD performed by using a standardized approach and compare outcomes of rendezvous and transluminal techniques.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Two tertiary-care centers.

PATIENTS

Consecutive jaundiced patients with distal malignant biliary obstruction who underwent EGBD after failed ERCP between July 2006 and December 2012 were included.

INTERVENTION

EGBD by using a standardized algorithm.

MAIN OUTCOME MEASUREMENTS

Technical success, clinical success, and adverse events.

RESULTS

During the study period, 35 patients underwent EGBD (rendezvous n = 13, transluminal n = 20). Technical success was achieved in 33 patients (94%), and clinical success was attained in 32 of 33 patients (97.0%). The mean postprocedure bilirubin level was 1.38 mg/dL in the rendezvous group and 1.33 mg/dL in the transluminal group (P = .88). Similarly, length of hospital stay was not different between groups (P = .23). There was no significant difference in adverse event rate between rendezvous and transluminal groups (15.4% vs 10%; P = .64). Long-term outcomes were comparable between groups, with 1 stent migration in the rendezvous group at 62 days and 1 stent occlusion in the transluminal group at 42 days after EGBD.

LIMITATIONS

Retrospective analysis, small number of patients, and selection bias.

CONCLUSION

EGBD is safe and effective when the described standardized approach is used. Stent occlusion is not common during long-term follow-up. Both rendezvous and direct transluminal techniques seem to be equally effective and safe. The latter approach is a reasonable alternative to rendezvous EGBD.

A novel technique for endoscopic ultrasound-guided biliary drainage

AIM: To describe a successful endoscopic ultrasound (EUS)-guided biliary drainage technique with high success and low complication rates.

METHODS: The recorded data of consecutive patients who presented to Siriraj Gastrointestinal Endoscopy Center, Siriraj Hospital in Bangkok, Thailand for treatment of malignant obstructive jaundice but failed endoscopic retrograde cholangiopancreatography and underwent subsequent EUS-guided biliary drainage were retrospectively reviewed. The patients’ baseline characteristics, clinical manifestations, procedure details, and post-procedure follow-up data were recorded and analyzed. Clinical outcomes were assessed by physical exam and standard laboratory tests. Technical success of the procedure was defined as completion of the stent insertion. Clinical success was defined as improvement of the patient’s overall clinical manifestations, in terms of general well-being evidenced by physical examination, restoration of normal appetite, and adequate biliary drainage. Overall median survival time was calculated as the time from the procedure until the time of death, and survival analysis was performed by the Kaplan-Meier method. The Student’s t-test and the χ² test were used to assess the significance of inter-group differences.

RESULTS: A total of 21 cases were enrolled, a single endoscopist performed all the procedures. The mean age was 62.8 years (range: 46-84 years). The sex distribution was almost equal, including 11 women and 10 men. Patients with failed papillary cannulation (33.3%), duodenal obstruction (42.9%), failed selective cannulation (19.0%), and surgical altered anatomy (4.8%) were considered candidates for EUS-guided biliary drainage. Six patients underwent EUS-guided choledochoduodenostomy and 15 underwent EUS-guided hepaticogastrostomy. The technique using non-cauterization and no balloon dilation was performed for all cases, employing the in-house manufactured tapered tip Teflon catheter to achieve the dilation. The technical success and clinical success rates of this technique were 95.2% and 90.5%, respectively. Complications included bile leakage and pneumoperitoneum, occurred at a rate of 9.5%. None of the patients died from the procedure. One patient presented with a biloma, a major complication that was successfully treated by another endoscopic procedure.

CONCLUSION: We present a highly effective EUS-guided biliary drainage technique that does not require cauterization or balloon dilation.

Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video)

BACKGROUND

EUS-guided biliary drainage (EUS-BD) was introduced as an effective alternative to percutaneous transhepatic biliary drainage after failed ERCP. However, EUS-BD is technically challenging. The intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure. Therefore, technical advances in guidewire manipulation may be required for EUS-BD.

OBJECTIVE

To evaluate our treatment algorithm for guidewire manipulation protocol for EUS-BD after failed ERCP.

DESIGN

Prospective, observational cohort study.

SETTING

A tertiary-care academic center.

PATIENTS

Forty-five consecutive patients undergoing EUS-BD failed ERCP.

INTERVENTIONS

Enhanced guidewire manipulation protocol (with a plane parallel to the long axis of the bile duct with an EUS needle tip or a new 0.025-inch guidewire in an extrahepatic approach and intrahepatic bile duct puncture of segment 2 and 4F cannula with guidewire probing in the intrahepatic approach) for rendezvous and antegrade therapy, EUS-BD with transluminal stenting for duodenal invasion, and crossover to another technique if each technique failed.

MAIN OUTCOME MEASUREMENTS

Technical and functional success rates and adverse event rate of the current treatment algorithm for EUS-BD.

RESULTS

The overall technical and functional success rates of EUS-BD in this study were 91% (intention to treat, n = 41/45) and 95% (per protocol, n = 39/41), respectively. Specifically, rendezvous (n = 20) and antegrade therapy (n = 14) were initially feasible in 34 of 45 patients (76%). With our protocol, 25 of 45 patients (56%) were eventually treated with rendezvous and antegrade therapy as a first-line or crossover treatment. EUS-guided biliary drainage with transluminal stenting in patients with duodenal invasion or failed antegrade therapy was feasible in the remaining 20 patients (44%). The overall adverse event rate of EUS-BD was 11%.

LIMITATIONS

Single-operator, nonrandomized study.

CONCLUSIONS

In this prospective study, our treatment algorithm with an enhanced guidewire manipulation protocol appeared to be technically feasible and effective. Given the favorable success rate and acceptable adverse event rate, this may be considered the standard treatment algorithm for future randomized trials of EUS-BD and percutaneous transhepatic biliary drainage.

Palliation of biliary and duodenal obstruction in patients with unresectable pancreatic cancer: endoscopy or surgery?

Patients with unresectable pancreatic adenocarcinoma often develop biliary and/or duodenal obstruction during the course of their disease. Jaundice, pruritis, nausea and vomiting impact negatively on the quality of life and chemotherapy must often be withheld until these symptoms are resolved. In the past, an open surgical palliative bypass was proposed, but the development of endoprosthetic stents has changed the management of these patients. The success rate for placement of duodenal and biliary stents is greater than 90% with low morbidity. Classical surgical bypass surgery includes biliary-digestive and gastro-jejunal anastomoses. Many studies have compared endoscopic and surgical treatment, and there is a clear advantage to endoscopic treatment in terms of quality of life and cost.

Endoscopic ultrasonographic access and drainage of the common bile duct

Endoscopic retrograde cholangiopancreatography (ERCP) is currently the standard of care for biliary drainage. In the hands of experienced endoscopists, conventional ERCP has a failed cannulation rate of 3% to 5%. Failures have traditionally been referred for either percutaneous transhepatic biliary drainage (PTBD) or surgery. Both PTBD and surgery have higher than desirable complication rates. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a novel and attractive alternative after failed ERCP. Many groups have reported on the feasibility, efficacy, and safety of this technique. This article reviews the indications and technique currently practiced in EUS-BD, including EUS-guided rendezvous, EUS-guided choledochoduodenostomy, and EUS-guided hepaticogastrostomy.

The increasing role of endoscopic ultrasound (EUS) in the management of pancreatic and biliary disease

Pancreatic and biliary disease continues to have a significant impact on the workload of the National Health Service (NHS), for which there exists a multimodality approach to investigation and diagnosis. Endoscopic ultrasound (EUS) is fast becoming a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but also because of its valuable role as a problem-solving tool and ever-improving ability in an interventional capacity. We provide a comprehensive review of the benefits of EUS in everyday clinical practice.

Successful endoscopic treatment of iatrogenic biloma as a complication of endosonography-guided hepaticogastrostomy: The first case report

Endosonography (EUS)-guided biliary drainage is a novel therapeutic option for patients with biliary obstruction after failed endoscopic retrograde cholangiopancreatography (ERCP). Many case reports and series worldwide have shown satisfactory clinical outcomes in terms of technical and clinical success rates, which approach 80%-100%. However, these procedures need to be performed by experts to minimize the possible complications, which have been reported in as many as 14-35% of patients. The most common complications encountered in these procedures are bile leakage, pneumoperitoneum, peritonitis, and stent related complications such as stent migration. Here, we report the case of a female patient who had cholangiocarcinoma and underwent EUS-guided hepaticogastrostomy after failed ERCP; stent malposition occurred during the procedure, leading to biloma formation that was successfully treated with EUS-guided biloma drainage.

Endoscopic ultrasonography as a therapeutic modality

PURPOSE OF REVIEW

Endoscopic ultrasonography (EUS) has taken on more of a therapeutic role in recent years. This review will focus on the therapeutic applications of EUS.

RECENT FINDINGS

Multiple studies on the therapeutic applications of EUS have been published. EUS facilitates endoscopic drainage of pancreatic fluid collections (PFCs) including walled-off pancreatic necrosis, management of refractory gastrointestinal bleeding from gastric varix or vasculature by fine-needle injection and decompression of obstructive pancreatic or biliary ductal systems following failed access by standard endoscopic or radiological techniques.

SUMMARY

The indications and role of therapeutic EUS have expanded rapidly in recent years. The procedures can be technically challenging, requiring expertise in both endosonography and endoscopic retrograde cholangiopancreatography. Refinement in echoendoscope design and dedicated accessories are required to further expand the applications of therapeutic EUS.