Preoperative endoscopic ultrasound-guided biliary drainage for primary drainage in obstructive jaundice

INTRODUCTION

Endoscopic transpapillary approach by endoscopic retrograde cholangiopancreatography (ERCP) is the established technique for preoperative biliary drainage (PBD). Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been reported to be a useful alternative technique after ERCP fail. However, the optimal strategy remain controversial.

AREA COVERED

This review summarizes the literature on EUS-BD techniques for PBD with a literature search using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials database between 2000 and 2023 using keywords for 'preoperative biliary drainage' and all types of EUS-BD techniques.

EXPERT OPINION

As there is no consensus on the optimal EUS-BD technique for PBD, selection of the EUS-BD approach depends on the patient's condition, the biliary obstruction site, the anastomosis after surgical intervention, and the preference of the endoscopist. However, we consider that EUS-HGS using a dedicated plastic stent may have some advantages in the adverse impact of surgical procedure because the location where the fistula is created by EUS-HGS is away from the site of the surgical procedure. Although there remain many issues that require further investigation, EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.

Application of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting in patients with malignant biliary obstruction after failed ERCP

BACKGROUND

This study was aimed at comparing the safety and effectiveness of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) and EUS-HGS combined with antegrade stenting (EUS-HGAS) in patients with malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Patients diagnosed with MBO and receiving EUS-HGS or EUS-HGAS from September 2015 to October 2020 were enrolled in this study. Clinical success, complications, reintervention rate, post-operative hospital stay, time to stent dysfunction, and patient death were compared.

RESULTS

A total of 45 patients (21 in the EUS-HGAS group and 24 in the EUS-HGS group) were enrolled in this study. In the EUS-HGAS group, 21 patients all achieved clinical success (100%); in the EUS-HGS group, 24 patients also achieved technical success (100%) (P > 0.05). The differences between pre- and post-operative TB and ALT and AST levels were greater in the single-step EUS-HGAS group (P < 0.05). The incidence of complications was 2 of 21 (9.5%) in the EUS-HGAS group and 5 of 24 (20.8%) in the EUS-HGS group (P > 0.05). The reintervention rate was 0 in the EUS-HGAS group and 1 (4.2%) in the EUS-HGS group (P > 0.05). Time to stent dysfunction or patient death was longer in the EUS-HGAS group (P < 0.05). The post-operative hospital stay was longer and the total cost was higher in the EUS-HGAS group.

CONCLUSION

EUS-HGAS was superior to EUS-HGS in terms of biliary drainage effectiveness and time to stent dysfunction or patient death in patients with MBO after failed ERCP. Furthermore, two-step EUS-HGAS may be safer in some patients.

EUS-Guided Antegrade Biliary Stenting Using a Novel Fully Covered Metal Stent (with Video)

BACKGROUND

Recently, endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) combined with antegrade stenting (AS) has been reported to be associated with longer stent patency and reduced procedure-related adverse events. In EUS-AS, an uncovered metal stent is usually selected to prevent stent misplacement or dislocation. However, because patient survival has improved with advances in chemotherapy, longer stent patency may be required.

AIM

The technical feasibility and safety of EUS-guided transhepatic biliary drainage combined with EUS-AS using a novel covered metal stent were evaluated.

METHODS

Patients with malignant biliary obstruction leading to obstructive jaundice, in whom standard ERCP had failed or was contraindicated, were enrolled in this study between July 2015 and October 2017. As the control group, patients undergoing EUS-AS using an uncovered metal stent were enrolled between October 2014 and June 2015.

RESULTS

A total of 39 patients were enrolled in this study. Among them, EUS-AS using a covered metal stent was performed in 17 patients and using an uncovered metal stent in the remaining 22 patients. Median stent patency including stent dysfunction and patient death was longer in the covered metal stent group (153 days) compared with that of the uncovered metal stent group (108 days) although there were no significant differences (P = 0.06). In only cases with stent dysfunction was median stent patency of the covered metal stent group significantly longer than that of the uncovered metal stent group (not available vs 150 days, P = 0.02).

CONCLUSIONS

In conclusion, EUS-guided transluminal biliary drainage combined with EUS-AS using a covered metal stent may be feasible and safe, although the indications for this procedure should be carefully considered.

Multicenter prospective evaluation study of endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting (with video)

BACKGROUND AND AIM

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is often indicated for advanced stage patients. Therefore it is important to prevent adverse events associated with EUS-HGS procedures and obtain long stent patency. EUS-guided antegrade stenting (AS) has been developed as an advanced technique. Thus, to prevent adverse events and achieve long stent patency, EUS-AS combined with EUS-HGS (EUS-HGAS) has been reported. The aim of the present study was to evaluate the technical feasibility and efficacy of EUS-HGAS in a multicenter, prospective study.

METHODS

This prospective study was carried out at each hospital of the Therapeutic Endoscopic Ultrasound Group. Primary endpoint of this multicenter prospective study was stent patency of EUS-HGAS.

RESULTS

A total of 49 patients were enrolled. Technical success rate of EUS-HGS was 95.9% (47/49). EUS-AS failed in five patients because the guidewire could not be advanced into the intestine across the bile duct obstruction site. Therefore, EUS-HGAS was successfully carried out in 40 patients (technical success rate: 85.7%). Median overall survival was 114 days. Median stent patency including stent dysfunction and patient death was 114 days. In contrast, mean stent patency was 320 days. Adverse events were seen in 10.2% (5/49) of cases. Hyperamylasemia was seen in four patients, and bleeding was seen in one patient.

CONCLUSIONS

The present study is the first to evaluate EUS-HGAS. EUS-HGAS has clinical benefit for obtaining long stent patency and avoiding adverse events, although the possibility of acute pancreatitis as a result of obstruction of the orifice of the pancreatic duct must be considered.

EUS-guided antegrade metal stenting with hepaticoenterostomy using a dedicated plastic stent with a review of the literature (with video)

Background and Objectives:

Recently, a novel EUS-guided biliary drainage (EUS-BD) technique consisting of EUS-guided antegrade stenting and EUS-guided hepaticoenterostomy (EUS-AS+HES) using two conventional metal stents (MS) has been reported to decrease adverse events and maintain longer stent patency for malignant biliary obstruction (MBO). However, only a few limited reports have evaluated this technique. Finally, dedicated plastic stents (PSs) have been developed to perform EUS-HES safely. The aim of the present study was to evaluate the outcome in EUS-AS+HES for MBO using the dedicated HES PSs.

Methods:

The results of a total of 23 patients who underwent EUS-AS+HES (18 simultaneous cases and 5 sequential cases) for MBO from October 2014 to July 2017 were retrospectively reviewed.

Results:

Technical and clinical success rates were 100% (23/23). Adverse events were seen in 8.7% (2/23); 2 cases of mild biliary peritonitis, which were successfully managed conservatively. Overall survival was 96 days and the median duration of stent patency, including stent dysfunction, patient death, and last follow-up, was 66.0 days (53 days in simultaneous cases and 78 days in sequential cases). Stent dysfunction was seen in 13.0% (3/23) of patients in 267, 263, and 135 days after the procedure.

Conclusions:

The novel EUS-BD technique, EUS-AS using MS plus HES employing a dedicated PS, was shown to be a feasible procedure for MBO and should yield longer duration of stent patency. Furthermore, sequential antegrade stenting in cases of occluded HES seems to be one other option instead of HES stent exchange. Further large-scale comparison studies with EUS-HES or EUS-AS are required to confirm its clinical efficacy.

Stent migration during EUS-guided hepaticogastrostomy in a patient with massive ascites: Troubleshooting using additional EUS-guided antegrade stenting

EUS-guided hepaticogastrostomy (EUS-HGS) is useful for treating obstructive jaundice. However, stent migration may sometimes occur both during and after the procedure. This report describes a patient with pancreatic cancer and massive ascites who underwent EUS-HGS combined with EUS-guided antegrade stenting (EUS-AS), with additional EUS-AS playing a role in troubleshooting for stent migration during EUS-HGS.