Endoscopic ultrasound-guided biliary drainage: A change in paradigm?

Tardive peritonitis after the endoscopic ultrasound‐guided hepaticogastorostomy: A case report

Endoscopic ultrasound‐guided biliary drainage (EUS‐BD) has become popular as a new drainage technique for malignant biliary strictures. Although EUS‐BD has been reported to show high technical and clinical success rates, the rate of adverse events is 15%. In particular, peritonitis, which is generally caused by bile leakage from the aspiration side during the procedure and occurs within a few days after EUS‐BD, needs to be considered as it can be fatal. In the present case, a jaundiced patient presented with unresectable pancreatic adenocarcinoma. Due to duodenal invasion, we performed EUS‐guided hepaticogastrostomy for biliary drainage. After the procedure, jaundice improved, and abdominal computed tomography (CT) showed only a small amount of air in the intrahepatic bile duct. However, 7 days after the procedure, the patient developed fever, and clinical findings indicated peritonitis. Abdominal CT showed food in the stomach accompanied by the appearance of perihepatic free air, with increased air in the intrahepatic bile duct. The duodenal stent insertion settled the peritonitis and improved the perihepatic free air and the air in the intrahepatic bile duct through the discharge of food from the stomach. To date, no case of tardive peritonitis associated with air leakage after EUS‐BD has been reported. We noted that even if there was no evidence of bile leakage after EUS‐BD, the possibility of tardive peritonitis due to gradual air leakage from the stent implantation side of the stomach should be considered, and careful follow‐up is needed.

Outcomes of EUS-guided transluminal gallbladder drainage in patients without cholecystitis

Background and Objectives:

Cholecystectomy is the gold standard for most gallbladder-related disease. However, many patients with gallbladder disease are poor surgical candidates. Current nonsurgical gallbladder drainage (GBD) methods include percutaneous cholecystostomy and endoscopic ultrasound-guided transluminal GBD (EUS-GBD). Outcomes for EUS-GBD for the treatment of noncholecystitis (NC) gallbladder disease have not been defined.

Materials and Methods:

Cases were identified using procedural data from a quaternary academic hospital for endoscopic procedures from 2015 to 2020. Patients who underwent EUS-GBD for acute cholecystitis, biliary colic, gallstone pancreatitis, and secondary prevention of gallstone disease were included.

Results:

Fifty-five cases of EUS-GBD were identified over the 5-year study period. Forty-one cases were performed for acute cholecystitis, and 15 were performed for other NC indications. Indications for NC drainage included primary treatment of symptomatic biliary colic and secondary prevention of gallstone pancreatitis and choledocholithiasis. There was no statistically significant difference in complications, mortality, or reintervention requirements. There was a 13.3% rate of immediate complications in the NC group, which were all medically managed.

Conclusions:

EUS-GBD appears to be a safe and effective way to manage gallstone disease in nonsurgical candidates with NC gallbladder-related disease. Overall complications and readmissions were infrequent. Complication rates were similar to those published in patients who underwent EUS-GBD for acute cholecystitis.

Relief of biliary obstruction: choosing between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography

Endoscopic ultrasound (EUS) was originally devised as a novel diagnostic technique to enable endoscopists to stage malignancies and acquire tissue. However, it rapidly advanced toward therapeutic applications and has provided gastroenterologists with the ability to effectively treat and manage advanced diseases in a minimally invasive manner. EUS-guided biliary drainage (EUS-BD) has gained considerable attention as an approach to provide relief in malignant and benign biliary obstruction for patients when endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible. Such instances occur in those with surgically altered anatomy, gastroduodenal obstruction, periampullary diverticulum or prior transampullary duodenal stenting. While ERCP remains the gold standard, a multitude of studies are showing that EUS-BD can be used as an alternative modality even in patients who could successfully undergo ERCP. This review will shed light on recent EUS-guided advancements and techniques in malignant and benign biliary obstruction.

Personalized Approach to the Role of Endoscopic Ultrasound in the Diagnosis and Management of Pancreaticobiliary Malignancies

Pancreaticobiliary malignancies arise from different areas within the pancreas and biliary tree. Endoscopic ultrasound (EUS) is a well-recognized diagnostic and therapeutic modality in the treatment of pancreaticobiliary diseases, and more specifically, pancreaticobiliary malignancies. Traditionally used for diagnostic purposes, EUS plays a critical role in tissue sampling and cancer staging. The emergence of the new field of interventional EUS has allowed EUS to also play a critical role in therapeutic management. Novel interventional EUS procedures such as EUS-guided gastrojejunostomy (EUS-GE), EUS-guided biliary drainage (EUS-BD), and EUS-guided gallbladder drainage (EUS-GLB) can be utilized to treat complications of pancreaticobiliary malignancies such as gastric outlet obstruction, obstructive jaundice, and cholecystitis. In addition, interventional EUS procedures can be utilized for the palliation of unresectable malignancies both for source control with EUS-radiofrequency ablation (EUS-RFA) and for the treatment of abdominal pain refractory to opioid medications with EUS-guided celiac axis neurolysis. However, patient selection remains a critical component in both diagnostic and therapeutic interventions and must be tailored to individual patient wishes, disease pathology, and overall prognosis.

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).

Endoscopic ultrasound-guided hepaticogastrostomy or hepaticojejunostomy without dilation using a stent with a thinner delivery system

Background and study aim  Use of endoscopic ultrasound-guided biliary drainage (EUS-BD) has recently increased. In EUS-BD, after puncturing the bile duct, dilation is performed and the stent is deployed. Due to adverse events (AEs) such as unexpected displacement of the guidewire, simplified procedures are required. Currently, stents with small-diameter delivery systems are being rapidly developed, expanding the possibilities for of EUS-BD without dilation. In this retrospective study, we aimed to evaluate the success rates and AEs in patients who underwent EUS-guided hepaticogastrostomy (EUS-HGS) or EUS-guided hepaticojejunostomy (EUS-HJS) without dilation. Patients and methods  Six consecutive patients with malignant biliary obstruction and failed transpapillary BD underwent EUS-HGS or EUS-HJS without dilation, deploying a 6-mm fully-covered self-expandable metallic stent with a 6-Fr delivery system. Results  The technical and clinical success rates were 100 %. There was one case each of stent migration and stent occlusion, and no other AEs were noted. Conclusions  EUS-HGS or EUS-HJS without dilation using a stent with a 6-Fr delivery system had high technical and clinical success rates; however, additional cases are required to validate the study findings.

Endoscopic ultrasound (EUS) guided choledocoduodenostomy in a patient with irresecable pancreas cancer and biliar obstruction using a luminal apposing metal stent (LAMS)

The endoscopic retrograde cholangiopancreatography (ERCP) is the election treatment of biliary obstruction. EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to PTBD with a high technical and clinical success rate, low risk of complications and a better quality of life for the patient. Case presentation we present the first case in Colombia of EUS-guided biliary drainage using luminal apposing metal stent (LAMS) in a patient with unresectable pancreatic adenocarcinoma with biliary obstruction in who ERCP was failed due to neoplastic invasion of the Vater papilla. Discussion Transhepatic biliary drainage has been the most common procedure for treatment of malignant biliary obstruction in cases which ERCP fails due to tumor infiltration of the duodenum or the Vater papilla. During the last decade the development of endoscopic ultrasound (EUS) has implied an alternative for biliary drainage in cases of failed ERCP, demonstrating advantages over Trans hepatic biliary drainage Conclusion Considering that EUS-CD is a safe procedure, with a high rate of technical and clinical success, low risk of complications.