Choledochoduodenostomy: Outcomes and limitations

Refractory benign biliary stricture due to chronic pancreatitis in two patients treated using endoscopic ultrasound-guided choledochoduodenostomy fistula creation: case reports

Benign biliary stricture (BBS) is a complication of chronic pancreatitis (CP). Despite endoscopic biliary stenting, some patients do not respond to treatment, and they experience recurrent cholangitis. We report two cases of CP with refractory BBS treated using endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) fistula creation. A 50-year-old woman and a 60-year-old man both presented with obstructive jaundice secondary to BBS due to alcoholic CP. They underwent repeated placement of a fully covered self-expandable metal stent for biliary strictures. However, the strictures persisted, causing repeated episodes of cholangitis. Therefore, an EUS-CDS was performed. The stents were eventually removed and the patients became stent-free. These fistulas have remained patent without cholangitis for more than 2.5 years. Fistula creation using EUS-CDS is an effective treatment option for BBS.

Utility of interventional endoscopic ultrasound in pancreatic cancer

Endoscopic ultrasound (EUS) has an important role in the management algorithm of patients with pancreatic ductal adenocarcinoma (PDAC), typically for its diagnostic utilities. The past two decades have seen a rapid expansion of the therapeutic capabilities of EUS. Interventional EUS is now one of the more exciting developments within the field of endoscopy. The local effects of PDAC tend to be in anatomical areas which are difficult to target and endoscopy has cemented itself as a key role in managing the clinical sequelae of PDAC. Interventional EUS is increasingly utilized in situations whereby conventional endoscopy is either impossible to perform or unsuccessful. It also adds a different dimension to the host of oncological and surgical treatments for patients with PDAC. In this review, we aim to summarize the various ways in which interventional EUS could benefit patients with PDAC and aim to provide a balanced commentary on the current evidence of interventional EUS in the literature.

Endoscopic ultrasound-guided biliary drainage: a literature review

Neoplasms of the biliopancreatic confluence may present with obstruction of the bile tract, leading to jaundice, pruritus and cholangitis. In these cases drainage of the bile tract is imperative. Endoscopic retrograde cholangiopancreatography (ERCP) with placement of a choledochal prosthesis is an effective treatment in about 90% of cases, even in experienced hands. In cases of ERCP failure, therapeutic options traditionally include surgical bypass by hepaticojejunostomy (HJ) or percutaneous transparietohepatic drainage (DPTH). In recent years, endoscopic ultrasound-guided biliary drainage techniques have gained space because they are less invasive, effective and have an acceptable incidence of complications. Endoscopic echo-guided drainage of the bile duct can be performed through the stomach (hepatogastrostomy), duodenum (choledochoduodenostomy) or by the anterograde drainage technique. Some services consider ultrasound-guided drainage of the bile duct the procedure of choice in the event of ERCP failure. The objective of this review is to present the main types of endoscopic ultrasound-guided biliary drainage and compare them with other techniques.

Experience-Related Factors in the Success of Beginner Endoscopic Ultrasound-Guided Biliary Drainage: A Multicenter Study

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become comparable to endoscopic retrograde cholangiopancreatography and is now considered a first-line intervention for certain biliary obstructions. Although analysis of experience-related factors may help achieve better outcomes and contribute to its wider adoption, no concrete evidence exists regarding the required operator or institutional experience levels. This study aimed to analyze experience-related factors at beginner multicenters. Patients who underwent EUS-BD using self-expandable metal stents and/or dedicated plastic stents during the study period (up to the first 25 cases since introducing the technique) were retrospectively enrolled from seven beginner institutions and operators. Overall, 90 successful (technical success without early adverse events) and 22 failed (technical failure and/or early adverse events) cases were compared. EUS-BD-related procedures conducted at the time of applicable EUS-BD by each institution/operator were evaluated. The number of institution-conducted EUS-BD procedures (≥7) and operator-conducted EUS screenings (≥436), EUS-guided fine-needle aspirations (FNA) (≥93), and EUS-guided drainages (≥13) significantly influenced improved EUS-BD outcomes (p = 0.022, odds ratio [OR], 3.0; p = 0.022, OR, 3.0; p = 0.022, OR, 3.0; and p = 0.028, OR, 2.9, respectively). Our threshold values, which significantly divided successful and failed cases, were assessed using receiver operating characteristic curve analysis and may provide useful approximate indications for successful EUS-BD.

EUS-guided choledochoduodenostomy for malignant biliary obstruction: A multicenter comparative study between plastic and metallic stents

Background and Objectives

EUS-guided choledochoduodenostomy (EUS-CDS) is commonly employed to address malignant biliary obstruction (MBO) after a failed ERCP. In this context, both self-expandable metallic stents (SEMSs) and double-pigtail stents (DPSs) are suitable devices. However, few data comparing the outcomes of SEMS and DPS exist. Therefore, we aimed to compare the efficacy and safety of SEMS and DPS at performing EUS-CDS.

Methods

We conducted a multicenter retrospective cohort study between March 2014 and March 2019. Patients diagnosed with MBO were considered eligible after at least one failed ERCP attempt. Clinical success was defined as a drop of direct bilirubin levels ≥ 50% at 7 and 30 postprocedural days. Adverse events (AEs) were categorized as early (≤7 days) or late (>7 days). The severity of AEs was graded as mild, moderate, or severe.

Results

Forty patients were included, 24 in the SEMS group and 16 in the DPS group. Demographic data were similar between the groups. Technical success rates and clinical success rates at 7 and 30 days were similar between the groups. Similarly, we found no statistical difference in the incidence of early or late AEs. However, there were two severe AEs (intracavitary migration) in the DPS group and none in the SEMS cohort. Finally, there was no difference in median survival (DPS 117 days vs. SEMS 217 days; P = 0.99).

Conclusion

EUS-guided CDS is an excellent alternative to achieve biliary drainage after a failed ERCP for MBO. There is no significant difference regarding the effectiveness and safety of SEMS and DPS in this context.

Drenagem biliar endoscópica ecoguiada: revisão da literatura

RESUMO Neoplasias da confluência biliopancreática podem cursar com obstrução da via biliar, levando a icterícia, prurido e colangite. Nesses casos a drenagem da via biliar é imperativa. A colangiopancreatografia endoscópica retrógrada (CPER) com colocação de prótese coledociana constitui tratamento eficaz em cerca de 90% dos casos mesmo em mãos experientes. Nos casos de insucesso da CPER, tradicionalmente as opções terapêuticas incluem a derivação cirúrgica por hepaticojejunostomia (HJ) ou drenagem percutânea transparietohepática (DPTH). Nos últimos anos as técnicas endoscópicas ecoguiadas de drenagem biliar ganharam espaço por serem menos invasivas, eficazes e apresentarem incidência aceitável de complicações. A drenagem endoscópica ecoguiada da via biliar pode ser realizada pelo estômago (hepatogastrostomia), duodeno (coledocoduodenostomia) ou pela técnica de drenagem anterógrada. Alguns serviços consideram a drenagem ecoguiada da via biliar o procedimento de escolha no caso de insucesso da CPER. O objetivo desta revisão é apresentar os principais tipos de drenagem biliar endoscópica ecoguiada e confrontá-los com outras técnicas.

How to perform EUS-guided biliary drainage

EUS-guided biliary drainage (EUS-BD) has recently gained widespread acceptance as a minimally invasive alternative method for biliary drainage. Even in experienced endoscopy centers, ERCP may fail due to inaccessibility of the papillary region, altered anatomy (particularly postsurgical alterations), papillary obstruction, or neoplastic gastric outlet obstruction. Biliary cannulation fails at first attempt in 5%-10% of cases even in the absence of these factors. In such cases, alternative options for biliary drainage must be provided since biliary obstruction is responsible for poor quality of life and even reduced survival, particularly due to septic cholangitis. The standard of care in many centers remains percutaneous transhepatic biliary drainage (PTBD). However, despite the high technical success rate with experienced operators, the percutaneous approach is more invasive and associated with poor quality of life. PTBD may result in long-term external catheters for biliary drainage and carry the risk of serious adverse events (SAEs) in up to 10% of patients, including bile leaks, hemorrhage, and sepsis. PTBD following a failed ERCP also requires scheduling a second procedure, resulting in prolonged hospital stay and additional costs. EUS-BD may overcome many of these limitations and offer some distinct advantages in accessing the biliary tree. Current data suggest that EUS-BD is safe and effective when performed by experts, although SAEs have been also reported. Despite the high number of clinical reports and case series, high-quality comparative studies are still lacking. The purpose of this article is to report on the current status of this procedure and to discuss the tools and techniques for EUS-BD in different clinical scenarios.

Comparison of Choledochoduodenostomy and Hepaticogastrostomy for EUS-Guided Biliary Drainage: A Meta-Analysis

Background

Although endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) or hepaticogastrostomy (EUS-HGS) has emerged as an option for patients of failed endoscopic retrograde cholangiopancreatography (ERCP), there has no agreement on which approach is preferred. Therefore, a meta-analysis was performed to examine the two methods.

Methods

We performed a comprehensive search in databases of PubMed, Embase, and Cochrane library to find relevant studies reporting the efficacy and safety of the two EUS-guided biliary drainage methods.

Results

In total, 12 studies with 623 patients (EUS-CDS: 303 and EUS-HGS: 320) were included. The cumulative technical success and clinical success for EUS-CDS and EUS-HGS was 95.0% (288/303), 93.1% (268/288), and 96.6% (309/320), 91.3% (282/309), respectively. Compared with EUS-HGS, the pooled odds ratio (OR) was 0.74 (95% CI 0.33–1.65; p = 0.46) for EUS-CDS technical success and 0.94 (95% CI 0.56–1.59; p = 0.83) for clinical success. The pooled difference in means of procedure time of EUS-CDS and EUS-HGS was −2.68 (95% CI −5.12 to −0.24; p = 0.03). The cumulative early adverse events for EUS-CDS and EUS-HGS was 12.2% (37/303) and 17.5% (56/320), respectively. Compared with EUS-HGS, the pooled OR of early adverse events for EUS-CDS was 0.58 (95% CI: 0.36–0.93; p = 0.02).

Conclusion

This meta-analysis further suggests EUS-CDS and EUS-HGS have equal high technical and clinical success, but EUS-CDS with a slightly short procedure time and with less early adverse events compared to EUS-HGS.

Informed Consent for Endoscopic Biliary Drainage: Time for a New Paradigm

Endoscopic retrograde cholangiopancreatography (ERCP) is considered as the first option in the management of malignant biliary obstruction. In case of ERCP failure, percutaneous transhepatic biliary drainage (PTBD) has been conventionally considered as the preferred rescue strategy. However, the use of endoscopic ultrasound (EUS) for biliary drainage (EUS-BD) has proved similarly high rates of technical success, when compared to PTBD. As a matter of fact, biliary drainage is maybe the most evident paradigm of the increasing interconnection between ERCP and EUS, and obtaining an adequate informed consent (IC) is an emerging issue. The aim of this commentary is to discuss the reciprocal roles of ERCP and EUS for malignant biliary obstruction, in order to provide a guide to help in developing an appropriate informed consent reflecting the new biliopancreatic paradigm.

Managing adverse events after endoscopic ultrasound-guided drainage of the biliary tract and pancreatic fluid collections: Narrative review (with video)

Endoscopic ultrasound (EUS)-guided therapeutic procedures have become increasingly common in clinical practice. The development of EUS-guided fine needle aspiration cytology led to the concept of interventional EUS. However, it carries a considerable risk of adverse events (AEs), which occur in approximately 23% of the procedures performed for the drainage of pancreatic fluid collections and 2.5-37.0% of those performed for drainage of the biliary tract. Although the vast majority of AEs occurring after EUS-guided drainage are mild, a deep understanding of such events is necessary for their appropriate management. Because EUS-guided drainage is a novel procedure, there have been few studies of the topic. To our knowledge, this is the first narrative review that focuses on the management and resolution of AEs occurring after EUS-guided drainage of pancreatic fluid collections or the biliary tract. We also include an explanatory video.

Common bile duct size in malignant distal obstruction and lumen-apposing metal stents: a multicenter prospective study

Background and study aims  Feasibility of EUS-guided choledochoduodenostomy (EUS-CDS) using available lumen-apposing stents (LAMS) is limited by the size of the common bile duct (CBD) (≤ 12 mm, cut-off for experts; 15 mm, cut-off for non-experts). We aimed to assess the prevalence and predictive factors associated with CBD size ≥ 12 and 15 mm in naïve patients with malignant distal biliary obstruction (MDBO). Patients and methods  This was a prospective cohort study involving 22 centers with assessment of CBD diameter and subjective feasibility of the EUS-CDS performance in naïve jaundiced patients undergoing EUS evaluation for MDBO. Results  A total of 491 patients (mean age 69 ± 12 years) with mean serum bilirubin of 12.7 ± 6.6 mg/dL entered the final analysis. Dilation of the CBD ≥ 12 and 15 mm was detected in 78.8 % and 51.9 % of cases, respectively. Subjective feasibility of EUS-CDS was expressed by endosonographers in 91.2 % for a CBD ≥ 12 mm and in 96.5 % for a CBD ≥ 15 mm. On multivariate analysis, age ( P  < 0.01) and bilirubin level ( P  ≤ 0.001) were the only factors associated with both CBD dilation ≥ 12 and ≥ 15 mm. These variables were poorly associated with the extent of duct dilation; however, based on them a prediction model could be constructed that satisfactorily predicted CBD size ≥ 12 mm in patients at least 70 years and a bilirubin level ≥ 7 mg/dL. Conclusions  Our study showed that at presentation in a large cohort of patients with MDBO, EUS-CDS can be potentially performed in three quarters to half of cases by expert and less experienced endosonographers, respectively. Dedicated stents or devices with different designs able to overcome the limitations of existing electrocautery-enhanced LAMS for EUS-CDS are needed.

Choledochoduodenostomy Versus Hepaticogastrostomy in Endoscopic Ultrasound-guided Drainage for Malignant Biliary Obstruction: A Meta-analysis and Systematic Review

OBJECTIVES

This study aimed to estimate the safety and efficacy of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for malignant biliary obstruction.

METHODS

We conducted a literature search using PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Studies that compared EUS-CDS and EUS-HGS were included in this study.

RESULTS

Thirteen studies were eligible for inclusion. The technical [odds ratio (OR): 0.95; 95% confidence interval (CI): 0.51-1.74) and clinical (OR: 1.13; 95%CI: 0.66-1.94) success rates of EUS-CDS were comparable to those of EUS-HGS. However, EUS-CDS had less reintervention (OR: 0.31; 95%CI: 0.16-0.63) and stent obstruction (OR: 0.48; 95%CI: 0.21-0.94) than EUS-HGS. Both groups had similar adverse events (OR: 1.00; 95%CI: 0.70-1.43) and overall survival (hazard ratio: 1.07; 95%CI: 0.58-1.97).

CONCLUSIONS

EUS-CDS and EUS-HGS have comparable technical and clinical success rates, adverse events, and overall survival. However, EUS-CDS has less reintervention and stent obstruction.

Endoscopic ultrasound-guided biliary drainage: Are we there yet?

Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.

Cleansing efficacy and safety of bowel preparation protocol using sodium picosulfate/magnesium citrate considering subjective experiences: An observational study

BACKGROUND

Research data from patient reports indicate that the least bearable part of colonoscopy is the administration of laxatives for bowel preparation.

AIM

To observe the intestinal cleansing efficacy and safety of sodium picosulfate/magnesium citrate and to discuss the patients’ experiences due to the procedure.

METHODS

Subjects hospitalized in the International Medical Center Ward of Peking University International Hospital, Beijing, China, from April 29 to October 29, 2020, for whom the colonoscopy was planned, were enrolled. Bowel preparation was performed using sodium picosulfate/magnesium citrate. The effect of bowel cleansing was evaluated according to the Ottawa Bowel Preparation Scale, defecation conditions and adverse reactions were recorded, and the comfort level and subjective satisfaction concerning medication were evaluated by the visual analogue scale/score (VAS).

RESULTS

The bowel preparation procedure was planned for all patients enrolled, which included 42 males and 22 females. The results showed an average liquid rehydration volume of 3000 mL, an average onset of action for the first dose at 89.04 min, an average number of bowel movements of 4.3 following the first dose, an average onset of action for the second dose at 38.90 min and an average number of bowel movements of 5.0 after the second dose. The total average Ottawa Bowel Preparation Scale score was 3.6, with 93.55% of bowel preparations in the “qualified” and 67.74% in the “excellent” grade. The average VAS score of effect on sleep was 0, and the average VAS score of perianal pain was also 0. The average VAS score for ease of taking and taste perception of the bowel cleanser was 10. Side effects included mild to moderate nausea (15.63%), mild vomiting (4.69%), mild to moderate abdominal pain (7.81%), mild to moderate abdominal distension (20.31%), mild palpitation (7.81%) and mild dizziness (4.69%).

CONCLUSION

Sodium picosulfate/magnesium citrate is effective and safe for bowel preparation before colonoscopy with high subjective patient acceptance, thus improving overall patient compliance.

Endoscopic ultrasound-guided hepaticogastrostomy using a partially covered metal stent in patients with malignant biliary obstruction after failed Endoscopic retrograde cholangiopancreatography

BACKGROUND AND AIM

The advent of endoscopic ultrasound-guided biliary drainage (EUS-BD) has provided an inimitable alternative for gaining biliary access in patients who fail conventional endoscopic drainage. The antimigratory features of the partially covered metal stent (PCMS), namely, the flange head and uncovered portion of the stent, makes it a valuable option in patients undergoing EUS-guided hepaticogastrostomy (EUS-HGS). The aim of the study is to evaluate the clinical outcome of EUS-BD via the hepaticogastrostomy approach using PCMS in patients with malignant biliary obstruction after failed ERCP.

METHODS

This is a single-center retrospective observational study of patients with malignant biliary obstruction undergoing EUS-HGS after failed ERCP between January 2018 and May 2019. The end-point of the study was to assess the technical and clinical success rate, as well as the stent- and procedure-related complications.

RESULTS

There were 20 subjects in this study. The average age was 71.8 ± 7.6 years. Most patients were male, 16 (80%). Inaccessible papillae was the most common indication for this procedure, 16 (80%). Technical success was achieved in all patients. The average procedural time was 39.9 ± 1.3 min. Mean preprocedural bilirubin levels were 348.6 ± 28.8 and subsequently decreased to 108.94 ± 37.1 μmol/L at 2 weeks postprocedure. The clinical success rate was 95% (19/20), with one patient requiring percutaneous transhepatic biliary drainage (PTBD). There were no stent- or procedure-related complications reported in this study.

CONCLUSION

EUS-HGS with PCMS is a feasible, effective, and safe alternative for biliary decompression in patients with failed endoscopic retrograde cholangiopancreatography (ERCP).