Advances in endoscopic ultrasound-guided biliary drainage: a comprehensive review

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.

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.

Placement of Palliative Stent With Guidance of a Percutaneous Transhepatic Stent

The incidence of pancreatic cancer has increased and outcomes have been improving with a multidisciplinary treatment approach. Pancreatoduodenectomy is the surgical approach for pancreatic head tumors; however, postoperative cholestasis or cholangitis may require endoscopic or percutaneous intervention. Placement of a percutaneous transhepatic cholangiographic (PTC) drain is a safe approach; however, this requires routine maintenance. This case demonstrates placement of a palliative biliary stent by a rendezvous approach using an in situ PTC drain.

Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic retrograde cholangiopancreatography is the preferred procedure for biliary drainage in benign and malignant obstructions. Endoscopic ultrasound-guided biliary drainage is an emerging technique for when endoscopic retrograde cholangiopancreatography fails. It is a highly versatile procedure with several options of access point, stent direction, and drainage route. Based on the current literature, the cumulative success rate is 88% to 93%, with an overall complication rate of 13% to 20%. Endoscopic ultrasound-guided biliary drainage seems to be an effective and valuable alternative technique after failed endoscopic retrograde cholangiopancreatography when performed by highly skilled endoscopists.

Endoscopic ultrasound guided biliary drainage: a comprehensive review

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become widely accepted over the past several years for complicated biliary drainage. When conventional endoscopic retrograde cholangiopancreatography (ERCP) is not successful or feasible due to a variety of constraints, an ultrasound-guided technique through intrahepatic and extrahepatic approaches allows adequate management of hepatobiliary obstruction. Other management alternatives include percutaneous transhepatic biliary drainages (PTBD) and complicated surgical approaches, both of which can be associated with increased morbidity and mortality. There are various technical approaches to allow successful biliary drainage which will be reviewed in this article.

Comparison of Endoscopic Ultrasonography Guided Biliary Drainage and Percutaneous Transhepatic Biliary Drainage in the Management of Malignant Obstructive Jaundice After Failed ERCP

AIMS

The aim of this study is to compare the efficacy and safety of endoscopic ultrasonography guided biliary drainage and percutaneous transhepatic biliary drainage in the management of malignant obstructive jaundice after failed ERCP.

METHODS

We performed a prospective study on 66 consecutive patients with malignant obstructive jaundice admitted to our hospital between January 2014 and January 2016 [corrected]. Patients were performed endoscopic ultrasonography-guided biliary drainage in 36 cases (group A) and percutaneous transhepatic biliary drainage in 30 cases (group B) according to the results of the draw. Data on the following variables were compared between the 2 groups: the technical success rate, the clinical success rate, complications, length of hospital stay, and hospital costs.

RESULTS

There was statistically significant difference in the clinical success rate (88.89% vs. 66.67%; χ=4.84), complications (5.56% vs. 23.33%; χ=4.39), length of hospital stay (11.54±3.73 d vs. 15.68±6.56 d; t=8.17) and hospital costs (23.52±8.44 thousand yuan vs. 32.81±6.06 thousand yuan; t=16.28) (P<0.05) between group A and group B. The technical success rate was higher in groups A than that in group B, although the difference did not reach statistical significance (94.44% vs. 86.67%; χ=1.20; P>0.05).

CONCLUSIONS

In the treatment of malignant obstructive jaundice, endoscopic ultrasonography guided biliary drainage is safer and more effective than percutaneous transhepatic biliary drainage when performed by experienced practitioners after failed ERCP. Its more widespread use is recommended.

Endoscopic Ultrasound-Guided Drainage of Pelvic Fluid Collections

Pelvic fluid collections can be challenging and often inaccessible because of their location and close proximity to adjacent organs and spine. This causes an increased risk for morbidity and poor outcomes. Recent advances in endoscopic ultrasound and therapeutic devices provide an effective, safe, and minimally invasive option to surgery or interventional radiology. These devices offer a relatively pain-free method that has shown good outcomes with minimal risk in recent case series, and has increasingly become the first-line treatment of choice. This article summarizes the current literature and the technique and considerations for successful drainage of these collections.

Endoscopic Ultrasound-Guided Biliary Access, with Focus on Technique and Practical Tips

In 1980, endoscopic ultrasound (EUS) was introduced as a diagnostic tool for evaluation of the pancreas. Since the introduction of curvilinear-array echoendoscopy, EUS has been used for a variety of gastrointestinal interventions, including fine needle aspiration, tumor ablation, and pancreatobiliary access. One of the main therapeutic roles of EUS is biliary drainage as an alternative to endoscopic retrograde biliary drainage (ERBD) or percutaneous transhepatic biliary drainage (PTBD). This article summarizes three different methods of EUS-guided biliary access, with focus on technique and practical tips.

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.

A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction

BACKGROUND AND STUDY AIMS

Selective biliary cannulation is unsuccessful in 5 % to 10 % of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard, but endoscopic ultrasound guided rendezvous (EUSr) have been increasingly used for biliary decompression in this patient population. Our aim was to compare the initial success rate, long-term efficacy, and safety of PBD and EUSr in relieving MDBO after failed ERC Patients and methods: A retrospective study involving 50 consecutive patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008 - 2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002 - 2008). Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates after biliary decompression.

RESULTS

The mean age at presentation was 66.5 (± 12.6 years), 28 patients (54.9 %) were female. The etiology of MDBO was pancreaticobiliary malignancy in 44 (88 %) and metastatic disease in 6 (12 %) cases. Biliary drainage was technically successful by EUSr in 19 (76 %) cases and by PBD in 25 (100 %) (P = 0.002). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (P = 0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (P = 0.001).

CONCLUSIONS

Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful, patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions. Meeting presentations: Annual Digestive Diseases Week 2015.

Malignant biliary obstruction: From palliation to treatment

Malignant obstruction of the bile duct from cholangiocarcinoma, pancreatic adenocarcinoma, or other tumors is a common problem which may cause debilitating symptoms and increase the risk of subsequent surgery. The optimal treatment - including the decision whether to treat prior to resection - depends on the type of malignancy, as well as the stage of disease. Preoperative biliary drainage is generally discouraged due to the risk of infectious complications, though some situations may benefit. Patients who require neoadjuvant therapy will require decompression for the prolonged period until attempted surgical cure. For pancreatic cancer patients, self-expanding metallic stents are superior to plastic stents for achieving lasting decompression without stent occlusion. For cholangiocarcinoma patients, treatment with percutaneous methods or nasobiliary drainage may be superior to endoscopic stent placement, with less risk of infectious complications or failure. For patients of either malignancy who have advanced disease with palliative goals only, the choice of stent for endoscopic decompression depends on estimated survival, with plastic stents favored for survival of < 4 mo. New endoscopic techniques may actually extend stent patency and patient survival for these patients by achieving local control of the obstructing tumor. Both photodynamic therapy and radiofrequency ablation may play a role in extending survival of patients with malignant biliary obstruction.

Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: predictors of successful outcome in patients who fail endoscopic retrograde cholangiopancreatography

BACKGROUND

Patients with failed endoscopic retrograde cholangiopancreatography (ERCP) are conventionally offered percutaneous transhepatic biliary drainage (PTBD). While PTBD is effective, it is associated with catheter-related complications, pain, and poor quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a minimally invasive endoscopic option increasingly offered as an alternative to PTBD. We compare outcomes of EUS-BD and PTBD in patients with biliary obstruction at a single tertiary care center.

METHODS

A retrospective review was performed in patients with biliary obstruction who underwent EUS-BD or PTBD after failed ERCP from June 2010 through December 2014 at a single tertiary care center. Patient demographics, procedural data, and clinical outcomes were documented for each group. The aim was to compare efficacy and safety of EUS-BD and PTBD and evaluate predictors of success.

RESULTS

A total of 60 patients were included (mean age 67.5 years, 65 % male). Forty-seven underwent EUS-BD, and thirteen underwent PTBD. Technical success rates of PTBD and EUS-BD were similar (91.6 vs. 93.3 %, p = 1.0). PTBD patients underwent significantly more re-interventions than EUS-BD patients (mean 4.9 versus 1.3, p < 0.0001), had more late (>24-h) adverse events (53.8 % vs. 6.6 %, p = 0.001) and experienced more pain (4.1 vs. 1.9, p = 0.016) post-procedure. In univariate analysis, clinical success was lower in the PTBD group (25 vs. 62.2 %, p = 0.03). In multivariable logistic regression analysis, EUS-BD was the sole predictor of clinical success and long-term resolution (OR 21.8, p = 0.009).

CONCLUSION

Despite similar technical success rates compared to PTBD, EUS-BD results in a lower need for re-intervention, decreased rate of late adverse events, and lower pain scores, and is the sole predictor for clinical success and long-term resolution. EUS-BD should be the treatment of choice after a failed ERCP.

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 palliation of malignant biliary strictures

Malignant biliary strictures often present late after the window for curative resection has elapsed. In such patients, the goal of therapy is typically focused on palliation. While historically, palliative measures were performed surgically, the advent of endoscopic intervention offers minimally invasive options to provide relief of symptoms, improve quality of life, and in some cases, increase survival of these patients. Some of these therapies, such as endoscopic biliary decompression, have become mainstays of treatment for decades, whereas newer modalities, including radiofrequency ablation, and photodynamic therapy offer additional options for patients with incurable biliary malignancies.

Choosing the appropriate strategy in managing malignant biliary obstruction

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) have shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depend on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, EUS guided biliary drainage, percutaneous transhepatic biliary drainage or surgical treatments are appropriate.

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.

Drainage-related Complications in Percutaneous Transhepatic Biliary Drainage: An Analysis Over 10 Years

BACKGROUND

Procedure-related complications of percutaneous transhepatic biliary drainage (PTBD) have been well documented in the literature. However, relatively restricted data are available concerning drainage-related complication rates in long-term PTBD therapy. The present retrospective study evaluated the extent and the nature of drainage complications during PTBD therapy and associated risk factors for these complications.

PATIENTS AND METHODS

Between June 1997 and May 2007, a total of 385 patients with PTBD were identified by analyzing the PTBD database and hospital charts, with a total of 2468 percutaneous biliary drainages being identified.

RESULTS

Among the identified patients, 243 (63%) had malignant and 142 (37%) had benign bile duct strictures. At least 1 drainage-related complication was observed in 40% of the patients. With respect to the total number of drains, prosthesis complications occurred in 23%. Occlusion, dislocation, and cholangitis were the most common complications observed during PTBD therapy. Risk factors for cholangitis and occlusion were malignant disease, prior occurrence of complications, and bilateral drainage. Proximal stenosis of the biliary system was close to significant.

CONCLUSIONS

Drainage-related complications are a major problem in PTBD therapy. The risk factors for occlusion and cholangitis discovered in this study can help to refine individual strategies to reduce the rate of these drainage complications.

Endoscopic ultrasound-guided biliary drainage: a review

OPINION STATEMENT

Endoscopic retrograde cholangiography (ERCP) has become the standard tool for diagnosis and treatment of patients with biliary obstruction. However, despite the reported success rate of >90 % in expert centers, the common bile duct may still be occasionally inaccessible due to anatomical or technical issues. Over the past decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an effective alternative over percutaneous transhepatic biliary drainage (PTBD) or surgical bypass for biliary drainage after unsuccessful ERCP. EUS-BD includes rendezvous techniques (EUS-RV), EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepatogastrostomy (EUS-HGS). Published data demonstrated high success rates especially for EUS-CDS and EUS-HGS. Complication rates, however, are also higher in these two techniques. The indications and anatomical requirements for the three techniques differ and should be considered complementary to each other. Most reported studies only included a small number of patients, and larger-scaled randomized trials are required to establish the efficacy among various EUS techniques and to compare to traditional means of radiological or surgical drainage.

Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy

AIM

To evaluate the efficacy of endoscopic ultrasound guided biliary drainage (EUS-BD) in patients with surgically altered anatomies.

METHODS

We performed a search of the MEDLINE database for studies published between 2001 to July 2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms "EUS drainage" and "altered anatomy". All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only full-text English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth I; group 2, Billroth II; group 4, Roux-en-Y with gastric bypass; and group 3, all other types.

RESULTS

Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion.

CONCLUSION

EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrograde-cholangiography in centers with expertise in EUS-BD procedures in a research setting.

Technical tips of endoscopic ultrasound-guided choledochoduodenostomy

Endoscopic ultrasound (EUS) is clinically useful not only as a diagnostic tool during EUS-guided fine needle aspiration, but also during interventional EUS. EUS-guided biliary drainage has been developed and performed by experienced endoscopists. EUS-guided choledocoduodenostomy (EUS-CDS) is relatively well established as an alternative biliary drainage method for biliary decompression in patients with biliary obstruction. The reported technical success rate of EUS-CDS ranges from 50% to 100%, and the clinical success rate ranges from 92% to 100%. Further, the over-all technical success rate was 93%, and clinical success rate was 98%. Based on the currently available literature, the overall adverse event rate for EUS-CDS is 16%. The data on the cumulative technical and clinical success rate for EUS-CDS is promising. However, EUS-CDS can still lead to several problems, so techniques or devices that are more feasible and safe need to be established. EUS-CDS has the potential to become a first-line biliary drainage procedure, although standardizing the technique in multicenter clinical trials and comparisons with endoscopic biliary drainage by randomized clinical trials are still needed.

Endoscopic ultrasonography guided drainage: summary of consortium meeting, May 21, 2012, San Diego, California

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary and pancreatic drainage. While ERCP is successful in about 95% of cases, a small subset of cases are unsuccessful due to altered anatomy, peri-ampullary pathology, or malignant obstruction. Endoscopic ultrasound-guided drainage is a promising technique for biliary, pancreatic and recently gallbladder decompression, which provides multiple advantages over percutaneous or surgical biliary drainage. Multiple retrospective and some prospective studies have shown endoscopic ultrasound-guided drainage to be safe and effective. Based on the currently reported literature, regardless of the approach, the cumulative success rate is 84%-93% with an overall complication rate of 16%-35%. endoscopic ultrasound-guided drainage seems a viable therapeutic modality for failed conventional drainage when performed by highly skilled advanced endoscopists at tertiary centers with expertise in both echo-endoscopy and therapeutic endoscopy.

Developments in flexible endoscopic surgery: a review

Flexible endoscopy is increasingly developing into a therapeutic instead of a purely diagnostic discipline. Improved visualization makes early lesions easily detectable and allows us to decide ad hoc on the required treatment. Deep enteroscopy allows the exploration of even the small bowel - for long a "white spot" for gastrointestinal endoscopy - and to perform direct treatment. Endoscopic submucosal dissection is a considerable step forward in oncologically correct endoscopic treatment of (early) malignant lesions. Though still technically challenging, it is increasingly facilitated by new manipulation techniques and tools that are being steadily optimized. Closure of wall defects and hemostasis could be improved significantly. Even the anatomy beyond the gastrointestinal wall is being explored by the therapeutic use of endoluminal ultrasound. Endosonographic-guided surgery is not only a suitable fallback solution if conventional endoscopic retrograde cholangiopancreatography fails, but even makes necrosectomy procedures, abscess drainage, and neurolysis feasible for the endoscopist. Newly developed endoscopic approaches aim at formerly distinctive surgical domains like gastroesophageal reflux disease, appendicitis, and cholecystitis. Combined endoscopic/laparoscopic interventional techniques could become the harbingers of natural orifice transluminal endoscopic surgery, whereas pure natural orifice transluminal endoscopic surgery is currently still in its beginnings.

Development of a swine bile duct dilation model using endoclips or a detachable snare under cap-assisted endoscopy

BACKGROUND

A reproducible large animal model of bile duct dilation for the preclinical testing of new biliary devices and for training endoscopic biliary intervention is required. Surgical methods are mainly used to produce large animal models of biliary obstruction.

OBJECTIVE

To develop an animal model of bile duct dilation using endoscopic methods and to compare the merits of endoclips and detachable snares for the obstruction of major duodenal papillae.

DESIGN

Proof of concept experimental study.

SETTINGS

Animal laboratory.

INTERVENTIONS

Endoscopic clipping of the major duodenal papilla or closure of the major duodenal papilla with a detachable snare.

MAIN OUTCOME MEASUREMENTS

Feasibility, efficacy, and safety of endoscopic methods to develop swine models with bile duct dilation were estimated by degree of dilation at the common bile duct (CBD), intrahepatic duct (IHD), and gallbladder (GB).

RESULTS

All animals survived until the end of the experiment. Clipping of the major duodenal papilla and closure of the major duodenal papilla with a detachable snare were performed successfully in all swine. No technical difficulty or adverse event occurred during the procedures. Biliary dilatations in all animals were observed on cholangiograms (mean Δ% of postprocedural and preprocedural maximum diameters: CBD, 301%; IHD, 223.5%; GB, 34.8%). Degree of bile duct dilation in the snare group tended to be greater (CBD, 367.3%; IHD, 298.3%; GB, 47.8%) than in the endoclip group (CBD, 234.7%; IHD, 148.7%; GB, 21.8%), but this difference was not significant. An analysis of degrees of dilation according to location in the biliary tree showed that the GB was not dilated as well as the CBD or IHD.

LIMITATIONS

Animal model.

CONCLUSION

The 2 endoscopic procedures described are effective and safe for creating a swine model of bile duct dilation and could be helpful for training biliary intervention and for endoscopic biliary studies.

Managing malignant biliary obstruction in pancreas cancer: choosing the appropriate strategy

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) has shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depends on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, percutaneous or surgical treatments are appropriate. Endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction.

Endoscopic ultrasound in gastroenterology: From diagnosis to therapeutic implications

Since its advent in 1980, the scope of endoscopic ultrasound (EUS) has grown to include a wide range of indications, and it is now being incorporated as an integral part of everyday practice in the field of gastroenterology. Its use is extending from an adjuvant imaging aid to utilization as a therapeutic tool for various gastrointestinal disorders. EUS was first used to visualize remote organs, such as the pancreas and abdominal lymph nodes. When fine needle aspiration was introduced, the indications for EUS expanded to include tissue sampling for diagnostic purposes. At the same time, the needle can be used to convey a potential therapy to the internal organs, allowing access to remote sites. In this review, we aim to highlight the expanding spectrum of EUS indications and uses in the field of gastroenterology.

Multicenter study on endoscopic ultrasound-guided expandable biliary metal stent placement: choice of access route, direction of stent insertion, and drainage route

BACKGROUND AND AIM

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) using expandable biliary metal stents has emerged as an acceptable alternative in patients with failed endoscopic retrograde cholangiopancreatography for malignant biliary obstruction. However, there is no consensus over the preferred access route (transhepatic or extrahepatic), direction of stent insertion (antegrade or retrograde) or drainage route (transluminal or transpapillary) in patients potentially suitable for multiple methods. The present study compares success and complication rates in patients undergoing EUS-BD via different methods.

METHODS

This was a multicenter retrospective analysis. Records of patients who underwent EUS-BD for malignant obstructive jaundice at four centers were entered in a standard database. Success and complications were compared for different techniques.

RESULTS

Sixty-eight patients were analyzed. EUS-BD was successful in 65 patients (95.6%). There was no significant difference in the success rates of different techniques. Complications were seen in 14 patients (20.6%) and mortality in three patients (4.4%). Complications were significantly higher for the transhepatic route compared to the transduodenal route (30.5% vs 9.3%, P=0.03). There was no significant difference in complication rates among transluminal and transpapillary stent placements, or direct and rendezvous stenting. Logistic regression analysis showed transhepatic access to be the only independent risk factor for complications (P=0.031, t=2.2).

CONCLUSION

EUS-BD can be carried out with high success rates regardless of the choice of access route, stent direction or drainage route. However, complications are significantly higher with transhepatic access. The transduodenal route should be chosen for EUS-guided and rendezvous stent placements, when both routes are available.

Endoscopic ultrasound-guided biliary drainage: an update

OPINION STATEMENT

Endoscopic retrograde cholangiopancreatography (ERCP) is currently the preferred procedure for biliary drainage in both benign and malignant obstructions. While ERCP is successful in approximately 95 % of cases, a small subset of cases are unsuccessful due to variant anatomy, ampullary pathology, or malignant luminal obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a promising route for biliary decompression that provides multiple advantages over percutaneous and surgical biliary drainage. Multiple retrospective as well as some prospective studies have shown EUS-BD to be safe and effective. Based on the current literature, the cumulative success rate is 84-93 %, regardless of the approach, with an overall complication rate of 16-35 %. EUS-BD appears to a viable therapeutic modality for failed ERCP when performed by highly skilled advanced endoscopists at tertiary centers with expertise in both echo-endoscopy and biliary endoscopy. Larger prospective multicenter randomized comparative studies are needed to further define indications, outcomes, and complications.

The role of endoscopic ultrasound in the diagnosis and therapy of gastrointestinal disorders

Endoscopic ultrasound is one of those diagnostic methods in gastrointestinal endoscopy which has developed rapidly in the last decade and has became exceedingly available to visualize the walls of the internal organs in details corresponding to histological layers, or analyze the adjacent structures. Fine needles and other endoscopic accessories can be introduced into the neighbouring tissues under the guidance of endoscopic ultrasound, and diagnostic and minimally invasive therapeutic interventions can be performed. The endoscopic ultrasound became more widely available in Hungary in the recent years. This review focuses on the indications, benefits and complications of diagnostic and therapeutic endoscopic ultrasound. We dedicate this article for gastroenterologists, surgeons, internists, pulmonologists, specialists in oncology and radiology. This recommendation was based on the consensus of the Board members of the Endoscopic Ultrasound Section of the Hungarian Gastroenterological Society. Orv. Hetil., 2014, 155(14), 526–540.

Endoscopic management of biliary disorders: diagnostic and therapeutic

The use of peroral endoscopy in the diagnosis of and therapy for biliary disorders has evolved immensely since the introduction of flexible fiberoptic endoscopes more than 50 years ago. Endoscopic retrograde cholangiopancreatography was introduced approximately a decade after flexible upper endoscopy and has evolved from a purely diagnostic procedure to almost exclusively a therapeutic procedure for managing biliary tract disorders. Endoscopic ultrasound, which continues to be a procedure of high diagnostic yield, is becoming a therapeutic modality for management of biliary diseases. This article discusses the diagnostic and therapeutic aspects of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound for evaluation and treatment of biliary diseases.

EUS access to the biliary tree

EUS-guided biliary access procedures can target the gallbladder or the bile duct for drainage in selected cases. EUS-guided gallbladder drainage offers comparable results to percutaneous cholecystostomy in high-surgical risk patients with acute cholecystitis refractory to medical treatment. The procedure is not yet widely available. Novel lumen-apposing stents may improve long-term outcomes, resulting in rapid dissemination. EUS access to the bile duct is coupled with ERCP techniques into a hybrid procedure, endosono-cholangiopancreatography (ESCP). ESCP admits six variant approaches to bile duct drainage based on the combination of two access routes (intrahepatic and extrahepatic) with three drainage routes: transmural, retrograde transpapillary and antegrade transpapillary. A thousand ESCP cases have been reported to date with good outcomes. When the expertise is available, ESCP is increasingly replacing percutaneous transhepatic biliary drainage to provide biliary drainage in patients in whom ERCP is not feasible, predominantly in the setting of palliation, but not limited to it.

Endoscopic guided biliary drainage: how can we achieve efficient biliary drainage?

Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

ERCP in the patient with surgically altered anatomy

Endoscopic retrogade cholangiopancreatography (ERCP) is a standard of care endoscopic technique using a conventional side-viewing duodenoscope to treat a wide variety of biliopancreatic pathologies. However, surgically altered gastric and/or small bowel anatomy renders ERCP more challenging because of several reasons. Depending on the type of surgical reconstruction, different endoscopic approaches have been developed in order to perform therapeutic ERCP. The current review highlights the latest ERCP developments to deal with biliopancreatic problems in patients with surgically altered anatomy, and discusses future directions of improvement.