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Will U, Füldner F, Buechner T, Meyer F. Endoscopic ultrasonography-guided drainage of the pancreatic duct (EUS-PD) in postoperative anastomotic stenosis after previous pancreatic resection. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:2039-2048. [PMID: 39642894 DOI: 10.1055/a-2435-4888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2024]
Abstract
As an alternative instead of a repeat surgical intervention, results (feasibility, safety, and technical and clinical success rate) of EUS-guided pancreatic duct drainage (EUS-PD) in a consecutive patient cohort because of symptomatic postoperative anastomotic stenosis as part of a unicenter observational study in daily clinical practice are presented.EUS-guided puncture (19-G needle) of the pancreatic duct, pancreaticography, and advancement of a guide wire (0.035 inches) via the anastomosis into the small intestine after previous dilatation of the transgastric access site (using ring knife): 1. if possible, balloon dilatation of the anastomosis and placement of a prosthesis as a gastro-pancreaticojejunostomy ("ring drainage", "gastro-pancreaticojejunostomy"); 2. if not possible (frustrating advancement of the guide wire), again, dilatation of the transgastric access site (using ring knife) and balloon dilatation with a following transgastric placement of a prosthesis (pancreaticogastrostomy).Out of the complete consecutive patient series with EUS-PD (n=119 cases) from 2004 to 2015, 34 patients (28.5%) were found with a medical history significant for previous surgical intervention at the pancreas who were approached using EUS-PD: in detail, pancreatic head resection in 1.) chronic pancreatitis (n=21; 61.8%) and 2.) malignant tumor lesions (n=13; 38.2%), resp. Pancreaticography was achieved in all subjects (n=34/34; rate, 100%). In 9/34 cases, a sufficient flow of contrast media via the anastomotic segment was detected; therefore, drainage was not placed. In the remaining 25 cases, the primary technical success (successful placement of drainage) rate was 64% (n=16/25 cases). In 9/25 patients, only dilatation using the passage of a ring knife over the guide wire and a balloon was performed. In detail, stent insertion was either not necessary because of good contrast flow via anastomosis (n=4) or not successful because of dislocation of the guide wire (n=5). However, these nine subjects underwent reintervention: in five patients, ring drainage (n=3) and transgastric drainage (n=2) were achieved, resulting in the definitive technical (drainage placement) success rate of 84% (n=21/25). In further detail, the two different techniques of drainage insertion such as pancreaticogastrostomy and gastro-pancreaticojejunostomy (ring drainage) were used in 11 patients (plastic stent, n=8; metal stent, n=3 [biliary wallstent, n=2; LAMS, n=1]) and ten subjects, resp.Finally, long-term clinical success was 92% (n=23/25).Overall, there were complications in 6/34 individuals (rate, 17.6%): bleeding, pressing ulcer by the stent, abscess within the lower sac, postinterventional pseudocyst (n=1 each), and paraluminal collection of contrast medium (n=2).Alternative EUS-PD is feasible and safe and can avoid surgical intervention; this can result in a distinct improvement in the quality of life, including an acceptable interventional risk. Because of the high technical demands, EUS-PD should only be performed in centers of interventional EUS, with great expertise in this field. Further clinical long-term observation, greater patient cohorts, evaluation of procedural knowledge and data, and further technical advances are required.
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Affiliation(s)
- Uwe Will
- Dept. of Gastroenterology, Hepatology, Diabetology and General Internal Medicine, Municipal Hospital ("SRH Wald-Klinikum"), Gera, Germany
| | - Frank Füldner
- Dept. of Gastroenterology, Hepatology, Diabetology and General Internal Medicine, Municipal Hospital ("SRH Wald-Klinikum"), Gera, Germany
| | - Theresa Buechner
- Municipal Hospital ("SRH Wald-Klinikum Gera"); Dept. of Gastroenterology, Hepatology, Diabetology and General Internal Medicine, Gera, Germany
| | - Frank Meyer
- Dept. of General, Abdominal, Vascular and Transplant Surgery, Otto-von-Guericke University with University Hospital, Magdeburg, Germany
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Comparison of Biliary Drainage Techniques for Malignant Biliary Obstruction: A Systematic Review and Network Meta-analysis. J Clin Gastroenterol 2022; 56:88-97. [PMID: 33780212 DOI: 10.1097/mcg.0000000000001512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/25/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage, and endoscopic ultrasound (EUS)-guided biliary drainage are all established techniques for drainage of malignant biliary obstruction. This network meta-analysis (NMA) was aimed at comparing all 3 modalities to each other. MATERIALS AND METHODS Multiple databases were searched from inception to October 2019 to identify relevant studies. All the patients were eligible to receive any one of the 3 interventions. Data extraction and risk of bias assessment was performed using standardized tools. Outcomes of interest were technical success, clinical success, adverse events, and reintervention. Direct meta-analyses were performed using the random-effects model. NMA was conducted using a multivariate, consistency model with random-effects meta-regression. The GRADE approach was followed to rate the certainty of evidence. RESULTS The final analysis included 17 studies with 1566 patients. Direct meta-analysis suggested that EUS-guided biliary drainage had a lower reintervention rate than ERCP. NMA did not show statistically significant differences to favor any one intervention with certainty across all the outcomes. The overall certainty of evidence was found to be low to very low for all the outcomes. CONCLUSIONS The available evidence did not favor any intervention for drainage of malignant biliary obstruction across all the outcomes assessed. ERCP with or without EUS should be considered first to allow simultaneous tissue acquisition and biliary drainage.
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Almuhaidb A, Olson D, Aadam AA. Advancements in Endoscopic Biliary Interventions by Gastroenterology. Semin Intervent Radiol 2021; 38:280-290. [PMID: 34393338 DOI: 10.1055/s-0041-1731266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.
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Affiliation(s)
- Aymen Almuhaidb
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dylan Olson
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - A Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Staroń R, Rzucidło M, Macierzanka A, Krawczyk M, Gutkowski K, Krupa L. Unresectable malignant obstructive jaundice: a 2-year experience of EUS-guided biliary drainage. BMJ Support Palliat Care 2021:bmjspcare-2020-002335. [PMID: 33653733 DOI: 10.1136/bmjspcare-2020-002335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 10/27/2020] [Accepted: 02/03/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Endoscopic biliary drainage is a first-line treatment in patients with unresectable malignant biliary obstruction. In most cases the drainage is conducted using endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage or endosonography-guided biliary drainage (EUS-BD) represents therapeutic options after unsuccessful ERCP. Here we report on 2 years experience in the management of patients diagnosed with malignant biliary obstruction using EUS-BD. METHODS Retrospective data were collected on patients who underwent EUS-BD due to malignant biliary obstruction at our centre between April 2016 and April 2018. Only patients who had two unsuccessful attempts of ERCP prior to EUS-BD were included. We analysed the technical success (ie, creation of anastomosis and successful placement of a stent) and complication rate of EUS-BD, and monitored changes in serum bilirubin and liver function tests after 2 days, and at least 2 weeks, following the procedure. RESULTS Screening of 1781 ERCP procedures performed in our department during the inclusion period led to the identification of 31 patients (18 women, age range 51-92 years, 58% with pancreatic cancer) who fulfilled the inclusion criteria. Hepaticogastrostomy and choledochoduodenostomy were performed in 12 and 19 patients, respectively. The technical success rate was 97% and the complication rate was 12.9%. EUS-BD resulted in a significant decrease in serum bilirubin (p<0.01). CONCLUSIONS EUS-BD represents a reasonable therapeutic option after unsuccessful ERCP in patients with malignant biliary obstruction. Possible complications have to be kept in mind and this procedure should be performed at centres experienced in ERCP and EUS.
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Affiliation(s)
- Robert Staroń
- Department of Gastroenterology and Hepatology with Internal Disease Unit, Specialist Voivodeship Hospital Frederic Chopin in Rzeszow, 35-055 Rzeszow, Poland
| | - Mateusz Rzucidło
- Department of Gastroenterology and Hepatology with Internal Disease Unit, Specialist Voivodeship Hospital Frederic Chopin in Rzeszow, 35-055 Rzeszow, Poland
| | - Adam Macierzanka
- Department of Colloid and Lipid Science, Gdańsk University of Technology, Gdansk, Województwo pomorskie, Poland
| | - Marcin Krawczyk
- Department of Medicine II, Saarland University Medical Centre, Saarland University, Homburg, Saarland, Germany
- Laboratory of Metabolic Liver Diseases, Centre for Preclinical Research, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Gutkowski
- Department of Gastroenterology and Hepatology with Internal Disease Unit, Specialist Voivodeship Hospital Frederic Chopin in Rzeszow, 35-055 Rzeszow, Poland
| | - Lukasz Krupa
- Department of Gastroenterology and Hepatology with Internal Disease Unit, Specialist Voivodeship Hospital Frederic Chopin in Rzeszow, 35-055 Rzeszow, Poland
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Artifon ELDA, Visconti TAC, Brunaldi VO. Choledochoduodenostomy: Outcomes and limitations. Endosc Ultrasound 2019; 8:S72-S78. [PMID: 31897383 PMCID: PMC6896435 DOI: 10.4103/eus.eus_62_19] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 08/27/2019] [Indexed: 12/21/2022] Open
Abstract
The EUS-guided biliary drainage (EUS-BD) has gained broad acceptance as the preferred approach after failed ERCP for malignant biliary obstruction. Despite the drainage route, namely, transhepatic or transduodenal, the technical and clinical success rates are high. Because of such good outcomes with tolerable adverse events (AEs) rate, the EUS-BD might soon even replace the ERCP for primary biliary decompression in patients at high risk of failed biliary cannulation. Among the EUS-BD techniques, the choledochoduodenostomy seems to carry the lower risk of AEs and should be considered the first-line EUS approach for biliary decompression.
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Affiliation(s)
- Everson Luiz De Almeida Artifon
- Department of Surgery, Hospital Das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil.,Gastrointestinal Endoscopy Unit, Hospital Das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Thiago A C Visconti
- Gastrointestinal Endoscopy Unit, Hospital Das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Vitor O Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital Das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Zhang HC, Tamil M, Kukreja K, Singhal S. Review of Simultaneous Double Stenting Using Endoscopic Ultrasound-Guided Biliary Drainage Techniques in Combined Gastric Outlet and Biliary Obstructions. Clin Endosc 2019; 53:167-175. [PMID: 31405265 PMCID: PMC7137573 DOI: 10.5946/ce.2019.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/24/2019] [Indexed: 12/16/2022] Open
Abstract
Concomitant malignant gastric outlet obstruction and biliary obstruction may occur in patients with advanced cancers affecting these anatomical regions. This scenario presents a unique challenge to the endoscopist in selecting an optimal management approach. We sought to determine the efficacy and safety of endoscopic techniques for treating simultaneous gastric outlet and biliary obstruction (GOBO) with endoscopic ultrasound (EUS) guidance for biliary drainage. An extensive literature search for peer-reviewed published cases yielded 6 unique case series that either focused on or included the use of EUS-guided biliary drainage (EUS-BD) with simultaneous gastroduodenal stenting. In our composite analysis, a total of 51 patients underwent simultaneous biliary drainage through EUS, with an overall reported technical success rate of 100% for both duodenal stenting and biliary drainage. EUS-guided choledochoduodenostomy or EUS-guided hepaticogastrostomy was employed as the initial technique. In 34 cases in which clinical success was ascribed, 100% derived clinical benefit. The common adverse effects of double stenting included cholangitis, stent migration, bleeding, food impaction, and pancreatitis. We conclude that simultaneous double stenting with EUS-BD and gastroduodenal stenting for GOBO is associated with high success rates. It is a feasible and practical alternative to percutaneous biliary drainage or surgery for palliation in patients with associated advanced malignancies.
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Affiliation(s)
- Hao Chi Zhang
- Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, TX, USA.,Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Monica Tamil
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Keshav Kukreja
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
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Bang JY, Varadarajulu S. Response. Gastrointest Endosc 2018; 88:573-574. [PMID: 30115311 DOI: 10.1016/j.gie.2018.04.2357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 04/26/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
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Okuno N, Hara K, Mizuno N, Kuwahara T, Iwaya H, Ito A, Kuraoka N, Matsumoto S, Polmanee P, Niwa Y. 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. J Gastroenterol Hepatol 2018; 33:1413-1421. [PMID: 29424011 DOI: 10.1111/jgh.14112] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 12/21/2022]
Abstract
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).
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Affiliation(s)
- Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamichi Kuwahara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiromichi Iwaya
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Ayako Ito
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Naosuke Kuraoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shimpei Matsumoto
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Petcharee Polmanee
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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Endoscopic Ultrasound-Guided Choledochoduodenostomy Using a Lumen-Apposing Metal Stent in Pancreatic Head Neoplasm-Associated Biliary Obstruction. ACG Case Rep J 2018; 5:e41. [PMID: 29915789 PMCID: PMC5992338 DOI: 10.14309/crj.2018.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 03/23/2018] [Indexed: 01/09/2023] Open
Abstract
Endoscopic ultrasound (EUS)-guided transluminal drainage of obstructed bile duct with conventional metal and plastic stents has been in practice for several years, but this modality carries its own potential complications and obstacles. Nevertheless, the novel Hot AXIOS stent (Boston Scientific Corp., Marlborough, MA) has been shown to overcome some of those factors, which justifies its application in a variety of clinical indications, such as EUS-guided choledochoduodenostomy (EUS-CDS) for biliary drainage after failed endoscopic retrograde cholangiopancreatography. We present a case of EUS-CDS with an electrocautery enhanced lumen-apposing stent for biliary drainage.
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Sportes A, Camus M, Greget M, Leblanc S, Coriat R, Hochberger J, Chaussade S, Grabar S, Prat F. 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. Therap Adv Gastroenterol 2017; 10:483-493. [PMID: 28567118 PMCID: PMC5424875 DOI: 10.1177/1756283x17702096] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 02/23/2017] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Adrien Sportes
- Gastroenterology Unit, Hôpital Cochin (AP-HP), University Paris Descartes, Paris, France
| | - Marine Camus
- Gastroenterology Unit, Hôpital Cochin (AP-HP), University Paris Descartes, Paris, France
| | - Michel Greget
- Interventional Radiology Unit CHRU Strasbourg, University of Strasbourg, France
| | - Sarah Leblanc
- Gastroenterology Unit, Hôpital Cochin (AP-HP), University Paris Descartes, Paris, France
| | - Romain Coriat
- Gastroenterology Unit, Hôpital Cochin (AP-HP), University Paris Descartes, Paris, France
| | - Jürgen Hochberger
- Gastroenterology Unit, Nouvel Hôpital Civil CHRU Strasbourg, University of Strasbourg, France
| | - Stanislas Chaussade
- Gastroenterology Unit, Hôpital Cochin (AP-HP), University Paris Descartes, Paris, France
| | - Sophie Grabar
- Biostatistics and Epidemiology, Hôtel Dieu (AP-HP), University Paris Descartes, Paris, France
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Nam HS, Kang DH. [Endoscopic Ultrasound-guided Biliary Drainage]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:164-171. [PMID: 28329918 DOI: 10.4166/kjg.2017.69.3.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The therapeutic role of endoscopic ultrasound (EUS) has continued to evolve in recent years. EUS-guided biliary drainage (EUS-BD) can be performed as an effective alternative to percutaneous drainage or surgical options when conventional Endoscopic retrograde cholangiopancreatography fails or is not possible. Depending on the access and exit routes of the stent, multiple approaches to EUS-BD have been proposed. Each patient should receive an individualized approach based on the patient's condition, anatomy, and endoscopist's experience, with an appropriate backup prepared. In high-volume centers, the cumulative success rate has been reported to be over 90%. However, the reported overall complication rate remains relatively high at 10-30%. Further studies are necessary to better understand the long-term results and standardize EUS-BD, including appropriate indications and optimal approach.
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Affiliation(s)
- Hyeong Seok Nam
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Moole H, Bechtold ML, Forcione D, Puli SR. A meta-analysis and systematic review: Success of endoscopic ultrasound guided biliary stenting in patients with inoperable malignant biliary strictures and a failed ERCP. Medicine (Baltimore) 2017; 96:e5154. [PMID: 28099327 PMCID: PMC5279072 DOI: 10.1097/md.0000000000005154] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/27/2016] [Accepted: 09/25/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In patients with inoperable malignant biliary strictures, endoscopic retrograde cholangiopancreatography (ERCP) guided biliary stenting fails in 5% to 10% patients due to difficult anatomy/inability to cannulate the papilla. Recently, endoscopic ultrasound guided biliary drainage (EUS-BD) has been described.Primary outcomes were to evaluate the biliary drainage success rates with EUS and compare it to percutaneous transhepatic biliary drainage (PTBD). Secondary outcomes were to evaluate overall procedure related complications. METHODS STUDY SELECTION CRITERIA:: Studies evaluating the efficacy of EUS-BD and comparing EUS-BD versus PTBD in inoperable malignant biliary stricture patients with a failed ERCP were included in this analysis. DATA COLLECTION AND EXTRACTION Articles were searched in Medline, PubMed, and Ovid journals. Two authors independently searched and extracted data. The study design was written in accordance to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Subgroup analyses of prospective studies and EUS-BD versus PTBD were performed. STATISTICAL METHOD Pooled proportions were calculated using fixed and random effects model. I statistic was used to assess heterogeneity among studies. RESULTS Initial search identified 846 reference articles, of which 124 were selected and reviewed. Sixteen studies (N = 528) that met the inclusion criteria were included in this analysis. In the pooled patient population, the percentage of patients that had a successful biliary drainage with EUS was 90.91% (95% CI = 88.10-93.38). The proportion of patients that had overall procedure related complications with EUS-PD was 16.46% (95% CI = 13.20-20.01). The pooled odds ratio for successful biliary drainage in EUS-PD versus PTBD group was 3.06 (95% CI = 1.11-8.43). The risk difference for overall procedure related complications in EUS-PD versus PTBD group was -0.21 (95% CI = -0.35 to -0.06). Relative risk for infectious complications and bile leak in EUS-BD versus PTBD was 0.25 (95% CI = 0.07-0.94) and 0.33 (95% CI = 0.12-0.87), respectively. CONCLUSIONS In patients with inoperable malignant biliary strictures who failed an ERCP guided biliary stenting, EUS-BD seems to be an excellent management option and superior to PTBD with higher successful biliary drainage rates and relatively fewer complications.
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Affiliation(s)
- Harsha Moole
- Division of General Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL
| | - Matthew L. Bechtold
- Division of Gastroenterology and Hepatology, University of Missouri-Columbia, Columbia, MO
| | - David Forcione
- Interventional Endoscopy Services, Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Srinivas R. Puli
- Division of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL
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Oh SY, Irani S, Kozarek RA. What are the current and potential future roles for endoscopic ultrasound in the treatment of pancreatic cancer? World J Gastrointest Endosc 2016; 8:319-329. [PMID: 27076870 PMCID: PMC4823670 DOI: 10.4253/wjge.v8.i7.319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/15/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic adenocarcinoma is the fourth leading cause of cancer-related death in the United States. Due to the aggressive tumor biology and late manifestations of the disease, long-term survival is extremely uncommon and the current 5-year survival rate is 7%. Over the last two decades, endoscopic ultrasound (EUS) has evolved from a diagnostic modality to a minimally invasive therapeutic alternative to radiologic procedures and surgery for pancreatic diseases. EUS-guided celiac plexus intervention is a useful adjunct to conventional analgesia for patients with pancreatic cancer. EUS-guided biliary drainage has emerged as a viable option in patients who have failed endoscopic retrograde cholangiopancreatography. Recently, the use of lumen-apposing metal stent to create gastrojejunal anastomosis under EUS and fluoroscopic guidance in patients with malignant gastric outlet obstruction has been reported. On the other hand, anti-tumor therapies delivered by EUS, such as the injection of anti-tumor agents, brachytherapy and ablations are still in the experimental stage without clear survival benefit. In this article, we provide updates on well-established EUS-guided interventions as well as novel techniques relevant to pancreatic cancer.
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Khashab MA, Van der Merwe S, Kunda R, El Zein MH, Teoh AY, Marson FP, Fabbri C, Tarantino I, Varadarajulu S, Modayil RJ, Stavropoulos SN, Peñas I, Ngamruengphong S, Kumbhari V, Romagnuolo J, Shah R, Kalloo AN, Perez-Miranda M, Artifon EL. Prospective international multicenter study on endoscopic ultrasound-guided biliary drainage for patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography. Endosc Int Open 2016; 4:E487-96. [PMID: 27092334 PMCID: PMC4831932 DOI: 10.1055/s-0042-102648] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 01/22/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative to traditional radiologic and surgical drainage procedures after failed endoscopic retrograde cholangiopancreatography (ERCP). However, prospective multicenter data are lacking. The aims of this study were to prospectively assess the short- and long-term efficacy and safety of EUS-BD in patients with malignant distal biliary obstruction. PATIENTS AND METHODS Consecutive patients at 12 tertiary centers (5 US, 5 European, 1 Asian, 1 South American) with malignant distal biliary obstruction and failed ERCP underwent EUS-BD. Technical success was defined as successful stent placement in the desired position. Clinical success was defined as a reduction in bilirubin by 50 % at 2 weeks or to below 3 mg/dL at 4 weeks. Adverse events were prospectively tracked and graded according to the American Society for Gastrointestinal Endoscopy (ASGE) lexicon's severity grading system. Overall survival and duration of stent patency were calculated using Kaplan-Meier analysis. RESULTS A total of 96 patients (mean age 66 years, female 45 %, pancreatic cancer 55 %) underwent EUS-BD. Stent placement (technical success) was achieved in 92 (95.8 %) patients (metallic stent 84, plastic stent 8). Mean procedure time was 40 minutes. Clinical success was achieved in 86 (89.5 %) patients. A total of 10 (10.5 %) adverse events occurred: pneumoperitoneum (n = 2), sheared wire (n = 1), bleeding (n = 1), bile leak (n = 3), cholangitis (n = 2), and unintentional perforation (n = 1); 4 graded as mild, 4 moderate, 1 severe, and 1 fatal (due to perforation). A total of 38 (44 %) patients died of disease progression during the study period. The median patient survival was 167 days (95 %CI 112 - 221) days. The 6-month stent patency rate was 95 % (95 %CI 94.94 - 95.06 %) and the 1-year stent patency was 86 % (95 %CI 85.74 - 86.26 %). CONCLUSION This study on EUS-BD demonstrates excellent efficacy and safety of EUS-BD when performed by experts. STUDY REGISTRATION NCT01889953.
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Affiliation(s)
- Mouen A. Khashab
- Johns Hopkins Medical Institute, Baltimore, MD, USA,Corresponding author Mouen A. Khashab, MD Johns Hopkins Hospital – Gastroenterology1800 Orleans Street Suite 7125BBaltimoreMD 21287USA+1-443-683-8335
| | - Schalk Van der Merwe
- Department of Hepatology, Division of Liver, and Pancreatico-Biliary Disorders, University Hospital Gastuisberg, University of Leuven, Leuven Belgium
| | | | | | - Anthony Y. Teoh
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | | | - Carlo Fabbri
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna Bellaria-Maggiore Hospital, Bologna, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | | | | | | | - Irene Peñas
- Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | | | - Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Raj Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Khashab MA, Messallam AA, Penas I, Nakai Y, Modayil RJ, De la Serna C, Hara K, El Zein M, Stavropoulos SN, Perez-Miranda M, Kumbhari V, Ngamruengphong S, Dhir VK, Park DH. International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs. choledochoduodenostomy approaches. Endosc Int Open 2016; 4:E175-81. [PMID: 26878045 PMCID: PMC4751013 DOI: 10.1055/s-0041-109083] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic ultrasound-guided biliary drainage (EUS-BD) can be performed entirely transgastrically (hepatogastrostomy/EUS-HG) or transduodenally (choledochoduodenostomy/EUS-CDS). It is unknown how both techniques compare. The aims of this study were to compare efficacy and safety of both techniques and identify predictors of adverse events. PATIENTS AND METHODS Consecutive jaundiced patients with distal malignant biliary obstruction who underwent EUS-BD at multiple international centers were included. Technical/clinical success, adverse events, stent complications, and survival were assessed. RESULTS A total of 121 patients underwent EUS-BD (CDS 60, HG 61). Technical success was achieved in 112 (92.56 %) patients (EUS-CDS 93.3 %, EUS-HG 91.8 %, P = 0.75). Clinical success was attained in 85.5 % of patients who underwent EUS-CDS group as compared to 82.1 % of patients who underwent EUS-HG (P = 0.64). Adverse events occurred more commonly in the EUS-HG group (19.67 % vs. 13.3 %, P = 0.37). Both plastic stenting (OR 4.95, 95 %CI 1.41 - 17.38, P = 0.01) and use of non-coaxial electrocautery (OR 3.95, 95 %CI 1.16 - 13.40, P = 0.03) were independently associated with adverse events. Length of hospital stay was significantly shorter in the CDS group (5.6 days vs. 12.7 days, P < 0.001). Mean follow-up duration was 151 ± 159 days. The 1-year stent patency probability was greater in the EUS-CDS group [0.98 (95 %CI 0.76 - 0.96) vs 0.60 (95 %CI 0.35 - 0.78)] but overall patency was not significantly different. There was no difference in median survival times between the groups (P = 0.36) CONCLUSIONS: Both EUS-CDS and EUS-HG are effective and safe techniques for the treatment of distal biliary obstruction after failed ERCP. However, CDS is associated with shorter hospital stay, improved stent patency, and fewer procedure- and stent-related complications. Metallic stents should be placed whenever feasible and non-coaxial electrocautery should be avoided when possible as plastic stenting and non-coaxial electrocautery were independently associated with occurrence of adverse events.
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Affiliation(s)
- Mouen A. Khashab
- Johns Hopkins Medical Institutions, Baltimore, MD, United States,Corresponding author Mouen A. Khashab, M.D Associate Professor of MedicineDirector of Therapeutic EndoscopyJohns Hopkins Hospital1800 Orleans St, Suite 7125 BBaltimore, MD 21205 (443) 287-1960
| | | | - Irene Penas
- Hospital Universitario–Roi Hortega, Valladolid, Spain.
| | | | | | | | - Kazuo Hara
- Aichi Cancer Center Hospital, Nagoya, Japan
| | - Mohamad El Zein
- Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | | | | | - Vivek Kumbhari
- Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | | | - Vinay K. Dhir
- Baladota Institute of Digestive Sciences, Mumbai, India.
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Holt BA, Hawes R, Hasan M, Canipe A, Tharian B, Navaneethan U, Varadarajulu S. Biliary drainage: role of EUS guidance. Gastrointest Endosc 2016. [PMID: 26215648 DOI: 10.1016/j.gie.2015.06.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS EUS-guided biliary drainage is a technique being increasingly used when ERCP fails, and it has been the focus of multiple studies and investment in recent years. However, the proportion of cases for which it is really indicated has not been established. The aim of this study is to determine how often EUS-guided biliary drainage is needed in a tertiary-care level therapeutic endoscopy unit. METHODS This is a prospective cohort study at a single tertiary-care center with a high volume of therapeutic endoscopy. A thousand consecutive ERCPs performed from November 1, 2013 to September 12, 2014 were screened, and those with previous biliary intervention were excluded (n = 476). EUS-guided biliary drainage was performed in suitable patients with failed ERCP and malignant biliary obstruction. The main outcome measures were the rates of ERCP failure and EUS-guided biliary drainage. RESULTS A total of 524 native papilla ERCPs were performed (41.2% male; median age 60 years, range 6-97 years; 9.4% outside failed ERCP; 1.9% surgically altered anatomy). The ampulla was reached in 518 (98.9%) and not reached in 6 (1.1%) because of surgically altered anatomy (n = 2), malignant duodenal stenosis (n = 3), or both (n = 1). The overall ERCP failure rate was 1.7% (9/524). Cannulation was successful in 99.4% (515/518) and unsuccessful in 0.6% (3/518) of cases in which the ampulla was reached. EUS-guided biliary drainage was indicated in 0.6% (3/524) of all referred native papilla ERCPs, or 33% (3/9) of those patients with failed ERCP; EUS-biliary drainage was successful in all cases. CONCLUSIONS In a tertiary-care center, use of advanced ERCP techniques results in a high technical success rate. EUS-guided biliary drainage was required in only 0.6% of native papilla ERCPs, and although a number of excellent indications exist, it should not replace good ERCP technique.
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Affiliation(s)
- Bronte A Holt
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Muhammad Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Ashley Canipe
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Benjamin Tharian
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | | | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
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Khashab MA, Levy MJ, Itoi T, Artifon ELA. EUS-guided biliary drainage. Gastrointest Endosc 2015; 82:993-1001. [PMID: 26384159 DOI: 10.1016/j.gie.2015.06.043] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 06/20/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Michael J Levy
- Department of Medicine and Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical, University, Tokyo, Japan
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Guedes HG, Lopes RI, Oliveira JFD, Artifon ELDA. Reality named endoscopic ultrasound biliary drainage. World J Gastrointest Endosc 2015; 7:1181-1185. [PMID: 26504507 PMCID: PMC4613807 DOI: 10.4253/wjge.v7.i15.1181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/01/2015] [Accepted: 09/18/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasound (EUS) is used for diagnosis and evaluation of many diseases of the gastrointestinal (GI) tract. In the past, it was used to guide a cholangiography, but nowadays it emerges as a powerful therapeutic tool in biliary drainage. The aims of this review are: outline the rationale for endoscopic ultrasound-guided biliary drainage (EGBD); detail the procedural technique; evaluate the clinical outcomes and limitations of the method; and provide recommendations for the practicing clinician. In cases of failed endoscopic retrograde cholangiopancreatography (ERCP), patients are usually referred for either percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Both these procedures have high rates of undesirable complications. EGBD is an attractive alternative to PTBD or surgery when ERCP fails. EGBD can be performed at two locations: transhepatic or extrahepatic, and the stent can be inserted in an antegrade or retrograde fashion. The drainage route can be transluminal, duodenal or transpapillary, which, again, can be antegrade or retrograde [rendezvous (EUS-RV)]. Complications of all techniques combined include pneumoperitoneum, bleeding, bile leak/peritonitis and cholangitis. We recommend EGBD when bile duct access is not possible because of failed cannulation, altered upper GI tract anatomy, gastric outlet obstruction, a distorted ampulla or a periampullary diverticulum, as a minimally invasive alternative to surgery or radiology.
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Torres-Ruiz MF, de la Mora-Levy JG, Alonso-Larraga JO, Sanchez-del Monte JC, Hernandez-Guerrero AI. Derivaciones biliodigestivas en obstrucción maligna. Drenaje guiado por ultrasonido endoscópico vs. percutáneo. Un estudio comparativo. ENDOSCOPIA 2015. [DOI: 10.1016/j.endomx.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the primary approach to drain an obstructed pancreatic or biliary duct. Failed biliary drainage is traditionally referred for percutaneous transhepatic biliary drainage or surgical bypass, which carry significantly higher morbidity and mortality rates compared with ERCP and transpapillary drainage. Endoscopic ultrasound provides a real-time imaging platform to access and deliver therapy to organs and tissues outside of the bowel lumen. The bile and pancreatic ducts can be directly accessed from the stomach and duodenum, offering an alternative to ERCP when this fails or is not feasible.
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Affiliation(s)
- Frank Weilert
- Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA, USA.
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21
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Weilert F, Binmoeller KF. Specially designed stents for translumenal drainage. GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.1016/j.gii.2015.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Hepaticogastrostomy or choledochoduodenostomy for distal malignant biliary obstruction after failed ERCP: is there any difference? Gastrointest Endosc 2015; 81:950-9. [PMID: 25500330 DOI: 10.1016/j.gie.2014.09.047] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 09/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND EUS-guided biliary drainage (BD) is an evolving alternative technique for patients with malignant biliary obstruction for which ERCP failed. OBJECTIVE To compare the outcomes of 2 nonanatomic EUS-guided BD routes: hepaticogastrostomy (HPG) and choledochoduodenostomy (CD). DESIGN Prospective, randomized trial. SETTING Tertiary endoscopic referral center. PATIENTS Forty-nine patients with unresectable distal malignant biliary obstruction and failed ERCP were included. The HPG group had 25 patients and the CD group had 24 patients. INTERVENTIONS EUS-guided HPG or CD. In all procedures, a biliary puncture with a 19-gauge needle followed by cholangiography, wire advancement, track dilation, and self-expandable metal stent deployment were performed. MAIN OUTCOME MEASUREMENTS Technical and clinical success, quality of life, adverse events, and survival. RESULTS The technical success rate was 96% for HPG and 91% for CD. The clinical success rate was 91% for HPG and 77% for CD. The mean procedural time was 47.8 minutes for HPG and 48.8 minutes for CD. The mean scores of quality of life were similar during follow-up. The overall adverse event rate was 16.3% (20% for the HPG group and 12.5% for the CD group). One patient with a bile leak required percutaneous biloma drainage. There was no statistical difference between the 2 techniques and no difference with regard to survival time between the 2 groups. LIMITATIONS Single-center study. CONCLUSION HPG and CD techniques are similar in efficacy and safety. Both HPG and CD seem valid alternative options for BD in patients with distal malignant biliary obstruction after failed ERCP.
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Khashab MA, Valeshabad AK, Afghani E, Singh VK, Kumbhari V, Messallam A, Saxena P, El Zein M, Lennon AM, Canto MI, Kalloo AN. A comparative evaluation of EUS-guided biliary drainage and percutaneous drainage in patients with distal malignant biliary obstruction and failed ERCP. Dig Dis Sci 2015; 60:557-65. [PMID: 25081224 DOI: 10.1007/s10620-014-3300-6] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 07/15/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound-guided biliary drainage (EGBD) may be a safe, alternative technique to percutaneous transhepatic biliary drainage (PTBD) in patients who fail ERCP. However, it is currently unknown how both techniques compare in terms of efficacy, safety, and cost. The aims of this study were to compare efficacy, safety, and cost of EGBD to that of PTBD. METHODS Jaundiced patients with distal malignant biliary obstruction who underwent EGBD or PTBD after failed ERCP were included. Technical success, clinical success, and adverse events between the two groups were compared. RESULTS A total of 73 patients with failed ERCP subsequently underwent EGBD (n = 22) or PTBD (n = 51). Although technical success was higher in the PTBD group (100 vs. 86.4 %, p = 0.007), clinical success was equivalent (92.2 vs. 86.4 %, p = 0.40). PTBD was associated with higher adverse event rate (index procedure: 39.2 vs. 18.2 %; all procedures including reinterventions: 80.4 vs. 15.7 %). Stent patency and survival were equivalent between both groups. Total charges were more than two times higher in the PTBD group (p = 0.004) mainly due to significantly higher rate of reinterventions (80.4 vs. 15.7 %, p < 0.001). CONCLUSION EGBD and PTBD are comparably effective techniques for treatment of distal malignant biliary obstruction after failed ERCP. However, EGBD is associated with decreased adverse events rate and is significantly less costly due to the need for fewer reinterventions. Our results suggest that EGBD should be the technique of choice for treatment of these patients at institutions with experienced interventional endosonographers.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA,
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Kahaleh M, Artifon ELA, Perez-Miranda M, Gaidhane M, Rondon C, Itoi T, Giovannini M. Endoscopic ultrasonography guided drainage: summary of consortium meeting, May 21, 2012, San Diego, California. World J Gastroenterol 2015; 21:726-41. [PMID: 25624708 PMCID: PMC4299327 DOI: 10.3748/wjg.v21.i3.726] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/29/2014] [Accepted: 06/21/2014] [Indexed: 02/07/2023] Open
Abstract
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.
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Song TJ, Lee SS, Park DH, Seo DW, Lee SK, Kim MH. Preliminary report on a new hybrid metal stent for EUS-guided biliary drainage (with videos). Gastrointest Endosc 2014; 80:707-711. [PMID: 25053527 DOI: 10.1016/j.gie.2014.05.327] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 05/27/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS-guided biliary drainage (EUS-BD) may be a feasible and useful alternative in patients with malignant biliary obstruction after failed ERCP. One of the main limitations of EUS-BD is the lack of devices specifically tailored to this technique. OBJECTIVE To evaluate a newly developed hybrid metal stent customized for EUS-BD. DESIGN A prospective, observational study. SETTING A tertiary academic referral center. PATIENTS A total of 27 consecutive patients with malignant biliary obstruction who were candidates for alternative techniques for biliary drainage because of failed ERCP were enrolled. INTERVENTIONS EUS-BD with a newly developed hybrid metal stent. MAIN OUTCOME MEASUREMENTS The technical and clinical success rates and adverse events, including proximal or distal stent migration and cholangitis. RESULTS EUS-guided hepaticogastrostomy was performed in 10 patients, and EUS-guided choledochoduodenostomy was performed in 17 patients. The technical success rate of EUS-BD with the hybrid metal stent was 100% (27/27), and clinical success was achieved in 96.3% (26/27) of the cases. Adverse events developed in 5 patients (5/27, 18.5%), including a self-limited pneumoperitoneum in 3 patients, minor bleeding in 1 patient, and abdominal pain in 1 patient. During the follow-up period (median 134 days), proximal or distal stent migration was not observed. LIMITATIONS This study was performed at a single center by a single experienced operator with a relatively small number of patients. CONCLUSION EUS-BD with a hybrid metal stent is technically feasible and can be an effective treatment for malignant biliary obstruction after failed ERCP. Hybrid metal stents may be used safely in EUS-BD, and they can prevent stent-related adverse events.
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Affiliation(s)
- Tae Jun Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang Soo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Do Hyun Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong Wan Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sung Koo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Luz LP, Al-Haddad MA, Sey MSL, DeWitt JM. Applications of endoscopic ultrasound in pancreatic cancer. World J Gastroenterol 2014; 20:7808-7818. [PMID: 24976719 PMCID: PMC4069310 DOI: 10.3748/wjg.v20.i24.7808] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/15/2014] [Accepted: 02/17/2014] [Indexed: 02/06/2023] Open
Abstract
Since the introduction of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA), EUS has assumed a growing role in the diagnosis and management of pancreatic ductal adenocarcinoma (PDAC). The objective of this review is to discuss the various applications of EUS and EUS-FNA in PDAC. Initially, its use for detection, diagnosis and staging will be described. EUS and EUS-FNA are highly accurate modalities for detection and diagnosis of PDAC, this high accuracy, however, is decreased in specific situations particularly in the presence of chronic pancreatitis. Novel techniques such as contrast-enhanced EUS, elastography and analysis of DNA markers such as k-ras mutation analysis in FNA samples are in progress and might improve the accuracy of EUS in the detection of PDAC in this setting and will be addressed. EUS and EUS-FNA have recently evolved from a diagnostic to a therapeutic technique in the management of PDAC. Significant developments in therapeutic EUS have occurred including advances in celiac plexus interventions with direct injection of ganglia and improved pain control, EUS-guided fiducial and brachytherapy seed placement, fine-needle injection of intra-tumoral agents and advances in EUS-guided biliary drainage. The future role of EUS and EUS in management of PDAC is still emerging.
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Artifon ELA, Perez-Miranda M. EUS-guided choledochoduodenostomy for malignant distal biliary obstruction palliation: an article review. Endosc Ultrasound 2014; 1:2-7. [PMID: 24949329 PMCID: PMC4062200 DOI: 10.7178/eus.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 02/08/2012] [Accepted: 02/19/2012] [Indexed: 12/17/2022] Open
Abstract
The EUS-guided biliary drainage is a new tool for the palliation of distal obstructive biliary lesions. The EUS-guided access, which creates a fistulization between the duodenal bulb and distal common biliary duct, is an effective method to relieve jaundice and has low morbidity and mortality, in patients with distal biliary obstruction (pancreatic mass or papillary câncer). This technique is called choledochoduodenostomy and is presented promptly in this article. The EUS-guided biliary drainage should be made within protocol conditions and done by very experienced endosonographers.
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Affiliation(s)
- Everson L A Artifon
- University of Sao Paulo (USP), Rua Guimaraes Passos, 260/121, Vila Mariana, Sao Paulo/SP, Brazil
| | - Manuel Perez-Miranda
- University of Sao Paulo (USP), Rua Guimaraes Passos, 260/121, Vila Mariana, Sao Paulo/SP, Brazil
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Artifon ELA. Endoscopic ultrasound-guided biliary drainage. Endosc Ultrasound 2014; 2:61-3. [PMID: 24949366 PMCID: PMC4062240 DOI: 10.4103/2303-9027.117687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 04/20/2013] [Indexed: 12/23/2022] Open
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Khashab MA, Valeshabad AK, Modayil R, Widmer J, Saxena P, Idrees M, Iqbal S, Kalloo AN, Stavropoulos SN. EUS-guided biliary drainage by using a standardized approach for malignant biliary obstruction: rendezvous versus direct transluminal techniques (with videos). Gastrointest Endosc 2013; 78:734-41. [PMID: 23886353 DOI: 10.1016/j.gie.2013.05.013] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/10/2013] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Shin EJ, Khashab M. The role of endoscopy in the treatment, management, and personalization of pancreatic cancer. Curr Probl Cancer 2013; 37:293-300. [PMID: 24331185 DOI: 10.1016/j.currproblcancer.2013.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
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.
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Affiliation(s)
- Manuel Perez-Miranda
- Gastroenterology Department, Hospital Universitario Rio Hortega, Av. Dulzaina,2, 47012 Valladolid, Spain.
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Abstract
Pancreatic cancer is the fourth leading cause of cancer mortality for both men and women in the United States. Overall 5-year survival from time of diagnosis is less than 5%. The only meaningful chance for cure results from early detection while the tumor remains resectable without locoregional extension or metastasis. Endoscopic ultrasound (EUS) is uniquely suited to the examination and treatment of the pancreas. Endoscopic ultrasound can provide important information with regard to disease stage including involvement of the mesenteric vasculature, adjacent organ invasion, and regional lymph node metastasis. In addition, EUS is considered the procedure of choice for tissue diagnosis of pancreatic cancer. More recently, EUS has developed therapeutic roles in an array of other clinical situations including EUS-guided fine needle injection, EUS-guided biliary drainage, celiac plexus neurolysis, brachytherapy, fiducial placement, and emerging antitumor agents delivered directly into the tumor.
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Affiliation(s)
- Jason J Lewis
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC, USA
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Khashab MA, Dewitt J. EUS-guided biliary drainage: is it ready for prime time? Yes! Gastrointest Endosc 2013; 78:102-5. [PMID: 23820411 DOI: 10.1016/j.gie.2013.03.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 03/04/2013] [Indexed: 02/08/2023]
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Tonozuka R, Itoi T, Sofuni A, Itokawa F, Moriyasu F. Endoscopic double stenting for the treatment of malignant biliary and duodenal obstruction due to pancreatic cancer. Dig Endosc 2013; 25 Suppl 2:100-8. [PMID: 23617659 DOI: 10.1111/den.12063] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 12/24/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND The purpose of the present study was to retrospectively evaluate endoscopic double stenting by endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD) and by endoscopic ultrasonography-guided biliary drainage (EUS-BD) for the treatment of non-resectable malignant biliary and duodenal obstruction. PATIENTS AND METHODS Medical records of 11 patients that underwent endoscopic double stenting from January 2008 to September 2012 were analyzed retrospectively. RESULTS Technical success rate was 100%, clinical success rate was 100%, early complication rate was 0% and late complication rate was 27.3% (cholangitis: two, perforation: one). Mean survival time from double stenting was 76.5 ± 67.8 days, mean patent period of the duodenal stent was 73.5 ± 69.7 days, and mean patent period of the biliary stent was 62.6 ± 60.4 days. Three (27.3%) patients were discharged (mean duration of hospitalization, 21.3 days). All patients could take food orally, and mean Gastric Outlet Obstruction Scoring System score after double stenting was 2.2 ± 0.9 points. ERCP-BD and EUS-BD were done in three and eight patients, respectively. There was no statistically significant difference between ERCP-BD and EUS-BD in terms of success rate and complication rate. CONCLUSION Our study revealed that endoscopic double stenting appears to be feasible and useful for the treatment of non-resectable malignant biliary and duodenal obstruction. In terms of selection criteria of ERCP-BD patients and EUS-BD patients, further prospective studies are mandatory.
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Affiliation(s)
- Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
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Itoi T, Itokawa F, Tsuchiya T, Tsuji S, Tonozuka R. Endoscopic ultrasound-guided choledochoantrostomy as an alternative extrahepatic bile duct drainage method in pancreatic cancer with duodenal invasion. Dig Endosc 2013; 25 Suppl 2:142-5. [PMID: 23617666 DOI: 10.1111/den.12065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 12/27/2012] [Indexed: 12/27/2022]
Abstract
Recently, endoscopic ultrasonography-guided bile duct drainage (EUS-BD) has become popular as an alternative method of biliary drainage in cases of failed endoscopic retrograde cholangiopancreatography. In terms of EUS-guided extrahepatic bile duct drainage, recently, EUS-guided choledochoantrostomy has been reported as a variation of EUS-BD. We describe a case of successful choledochoantrostomy using a fully covered self-expandable metallic stent. We conclude that EUS-guided choledochoantrostomy should be one option for biliary decompression. In particular, if patients have duodenal strictures, with or without a duodenal metal stent, it seems to be an ideal alternative to choledochoduodenostomy.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
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Rerknimitr R, Angsuwatcharakon P, Ratanachu-ek T, Khor CJL, Ponnudurai R, Moon JH, Seo DW, Pantongrag-Brown L, Sangchan A, Pisespongsa P, Akaraviputh T, Reddy ND, Maydeo A, Itoi T, Pausawasdi N, Punamiya S, Attasaranya S, Devereaux B, Ramchandani M, Goh KL. Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma. J Gastroenterol Hepatol 2013; 28:593-607. [PMID: 23350673 DOI: 10.1111/jgh.12128] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2012] [Indexed: 12/13/2022]
Abstract
Hilar cholangiocarcinoma (HCCA) is one of the most common types of hepatobiliary cancers reported in the world including Asia-Pacific region. Early HCCA may be completely asymptomatic. When significant hilar obstruction develops, the patient presents with jaundice, pale stools, dark urine, pruritus, abdominal pain, and sometimes fever. Because no single test can establish the definite diagnosis then, a combination of many investigations such as tumor markers, tissue acquisition, computed tomography scan, magnetic resonance imaging/magnetic resonance cholangiopancreatography, endoscopic ultrasonography/intraductal ultrasonography, and advanced cholangioscopy is required. Surgery is the only curative treatment. Unfortunately, the majority of HCCA has a poor prognosis due to their advanced stage on presentation. Although there is no survival advantage, inoperable HCCA managed by palliative drainage may benefit from symptomatic improvement. Currently, there are three techniques of biliary drainage which include endoscopic, percutaneous, and surgical approaches. For nonsurgical approaches, stent is the most preferred device and there are two types of stents i.e. plastic and metal. Type of stent and number of stent for HCCA biliary drainage are subjected to debate because the decision is made under many grounds i.e. volume of liver drainage, life expectancy, expertise of the facility, etc. Recently, radio-frequency ablation and photodynamic therapy are promising techniques that may extend drainage patency. Through a review in the literature and regional data, the Asia-Pacific Working Group for hepatobiliary cancers has developed statements to assist clinicians in diagnosing and managing of HCCA. After voting anonymously using modified Delphi method, all final statements were determined for the level of evidence quality and strength of recommendation.
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Affiliation(s)
- Rungsun Rerknimitr
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Abstract
The causes of obstructive jaundice are varied, and timely, accurate methods of investigation are essential to avoid the development of complications. Imaging, invasive or non-invasive, should be carefully selected depending on the suspected underlying pathology in order to determine the degree and level of obstruction along with tissue acquisition and staging where relevant. Several imaging techniques will also allow subsequent therapeutic interventions to be carried out. This article reviews advances in the investigation of obstructive jaundice, highlighting recent developments, many of which at present remain restricted to large centres of expertise, but are likely to become more widespread in use as research progresses and local experience continues to improve.
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Affiliation(s)
- J Addley
- Department of Gastroenterology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK.
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Henry WA, Singh VK, Kalloo AN, Khashab MA. Simultaneous EUS-guided transbulbar pancreaticobiliary drainage (with video). Gastrointest Endosc 2012; 76:1065-7, 1067.e1-2. [PMID: 22197478 DOI: 10.1016/j.gie.2011.09.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Accepted: 09/26/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Winoah A Henry
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland 21205, USA
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Prachayakul V, Aswakul P. Successful endoscopic treatment of iatrogenic biloma as a complication of endosonography-guided hepaticogastrostomy: The first case report. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:202-204. [PMID: 23687611 DOI: 10.4161/jig.23750] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 12/10/2012] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Varayu Prachayakul
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Song TJ, Hyun YS, Lee SS, Park DH, Seo DW, Lee SK, Kim MH. Endoscopic ultrasound-guided choledochoduodenostomies with fully covered self-expandable metallic stents. World J Gastroenterol 2012; 18:4435-40. [PMID: 22969210 PMCID: PMC3436062 DOI: 10.3748/wjg.v18.i32.4435] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 08/16/2012] [Accepted: 08/18/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with a fully covered self-expandable metallic stent (FCSEMS).
METHODS: From April 2009 to August 2010, 15 patients with distal malignant biliary obstructions who were candidates for alternative techniques for biliary decompression due to a failed endoscopic retrograde cholangiopancreatography (ERCP) were included. These 15 patients consisted of 8 men and 7 women and had a median age of 61 years (range: 30-91 years). The underlying causes of the distal malignant biliary obstruction were pancreatic cancer (n = 9), ampulla of Vater cancer (n = 2), renal cell carcinoma (n = 1), advanced gastric cancer (n = 1), lymphoma (n = 1), and duodenal cancer (n = 1).
RESULTS: The technical success rate of EUS-CDS with an FCSEMS was 86.7% (13/15), and functional success was achieved in 100% (13/13) of those cases. In two patients, the EUS-CDS failed because an FCSEMS with a delivery device could not be passed into the common bile duct. The mean duration of stent patency was 264 d. Early adverse events developed in three patients (3/13, 23.1%), including self-limited pneumoperitoneum in two patients and cholangitis requiring stent reposition in one patient. During the follow-up period (median: 186 d, range: 52-388 d), distal stent migration occurred in four patients (4/13, 30.8%). In 3 patients, the FCSEMS could be reinserted through the existing choledochoduodenal fistula tract.
CONCLUSION: EUS-CDS with an FCSEMS is technically feasible and can lead to effective palliation of distal malignant biliary obstructions after failed ERCP.
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Kim TH, Kim SH, Oh HJ, Sohn YW, Lee SO. Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction. World J Gastroenterol 2012; 18:2526-32. [PMID: 22654450 PMCID: PMC3360451 DOI: 10.3748/wjg.v18.i20.2526] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 02/06/2012] [Accepted: 02/16/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the utility of endoscopic ultrasound-guided biliary drainage (EUS-BD) with a fully covered self-expandable metal stent for managing malignant biliary stricture.
METHODS: We collected data from 13 patients who presented with malignant biliary obstruction and underwent EUS-BD with a nitinol fully covered self-expandable metal stent when endoscopic retrograde cholangiopancreatography (ERCP) fails. EUS-guided choledochoduodenostomy (EUS-CD) and EUS-guided hepaticogastrostomy (EUS-HG) was performed in 9 patients and 4 patients, respectively.
RESULTS: The technical and functional success rate was 92.3% (12/13) and 91.7% (11/12), respectively. Using an intrahepatic approach (EUS-HG, n = 4), there was mild peritonitis (n = 1) and migration of the metal stent to the stomach (n = 1). With an extrahepatic approach (EUS-CD, n = 10), there was pneumoperitoneum (n = 2), migration (n = 2), and mild peritonitis (n = 1). All patients were managed conservatively with antibiotics. During follow-up (range, 1-12 mo), there was re-intervention (4/13 cases, 30.7%) necessitated by stent migration (n = 2) and stent occlusion (n = 2).
CONCLUSION: EUS-BD with a nitinol fully covered self-expandable metal stent may be a feasible and effective treatment option in patients with malignant biliary obstruction when ERCP fails.
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The Spectrum of Endoscopic Ultrasound Intervention in Biliary Diseases: A Single Center's Experience in 31 Cases. Gastroenterol Res Pract 2012; 2012:680753. [PMID: 22654900 PMCID: PMC3357930 DOI: 10.1155/2012/680753] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 01/29/2012] [Accepted: 02/12/2012] [Indexed: 12/13/2022] Open
Abstract
Background and Aim. EUS-guided intervention (EGI) for biliary therapy has been increasingly used in recent years. This report aims to describe the spectrum and experience of EUS-guided interventions in biliary diseases in a single-tertiary center.
Methods. All patients with EGI were analyzed retrospectively by retrieving data from a prospectively stored endoscopic database between January 2006 and September 2010. Results. There were 31 cases with EGIs (17 female, 14 male) with a mean age ± SD of 58.03 ± 16.89 years. The majority of cases (17/31; 55%) were ampullary or pancreatic cancers with obstructive jaundice. The major indications for EGI were obstructive jaundice (n = 16) and cholangitis (n = 9). The EGIs were technically successful in 24 of the 31 cases (77%). The success rate for the first 3 years was 8 of 13 procedures (61.5%) as compared to that of the last 2 years (16/18 procedures (89%); P = 0.072). Twenty-three of the 24 cases (96%) with technical success for stent placement also had clinical success in terms of symptom improvement. The complications were major in 4 (13%) and minor in 7 (23%) patients. Conclusion. The EUS-guided drainage for biliary obstruction, acute cholecystitis, bile leak, and biloma was an attractive alternative and should be handled in expert centers.
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Yamao K, Hara K, Mizuno N, Hijioka S, Imaoka H, Bhatia V, Shimizu Y. Endoscopic ultrasound-guided choledochoduodenostomy for malignant lower biliary tract obstruction. Gastrointest Endosc Clin N Am 2012; 22:259-69, ix. [PMID: 22632948 DOI: 10.1016/j.giec.2012.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is a novel alternative to percutaneous transhepatic biliary drainage, when endoscopic retrograde cholangiopancreatography is unsuccessful in patients with malignant lower biliary obstruction. Some case series and a few prospective studies of EUS-CDS have reported high technical and functional success rates but with the downside of high early complication rates, albeit mostly nonsevere. In addition, the stents placed by EUS-CDS had a longer patency than transpapillary biliary stents.
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Affiliation(s)
- Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-Ku, Nagoya 464-8681, Japan.
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Jang JW, Lee SS, Song TJ, Hyun YS, Park DH, Seo DW, Lee SK, Kim MH, Yun SC. Endoscopic ultrasound-guided transmural and percutaneous transhepatic gallbladder drainage are comparable for acute cholecystitis. Gastroenterology 2012; 142:805-11. [PMID: 22245666 DOI: 10.1053/j.gastro.2011.12.051] [Citation(s) in RCA: 172] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 12/22/2011] [Accepted: 12/31/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Endoscopic ultrasound-guided transmural gallbladder drainage (EUS-GBD) is an alternative to percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute, high-risk, or advanced-stage cholecystitis who do not respond to initial medical treatment and cannot undergo emergency cholecystectomy. However, the technical feasibility, efficacy, and safety of EUS-GBD and PTGBD have not been compared. METHODS Fifty-nine patients with acute cholecystitis, who did not respond to initial medical treatment and were unsuitable for an emergency cholecystectomy, were chosen randomly to undergo EUS-GBD (n = 30) or PTGBD (n = 29). The technical feasibility, efficacy, and safety of EUS-GBD and PTGBD were compared. RESULTS EUS-GBD and PTGBD showed similar technical (97% [29 of 30] vs 97% [28 of 29]; 95% 1-sided confidence interval lower limit, -7%; P = .001 for noninferiority margin of 15%) and clinical (100% [29 of 29] vs 96% [27 of 28]; 95% 1-sided confidence interval lower limit, -2%; P = .0001 for noninferiority margin of 15%) success rates, and similar rates of complications (7% [2 of 30] vs 3% [1 of 29]; P = .492 in the Fisher exact test) and conversions to open cholecystectomy (9% [2 of 23] vs 12% [3 of 26]; P = .999 in the Fisher exact test). The median post-procedure pain score was significantly lower after EUS-GBD than after PTGBD (1 vs 5; P < .001 in the Mann-Whitney U test). CONCLUSIONS EUS-GBD is comparable with PTGBD in terms of the technical feasibility and efficacy; there were no statistical differences in the safety. EUS-GBD is a good alternative for high-risk patients with acute cholecystitis who cannot undergo an emergency cholecystectomy.
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Affiliation(s)
- Ji Woong Jang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Chavalitdhamrong D, Draganov PV. Endoscopic ultrasound-guided biliary drainage. World J Gastroenterol 2012; 18:491-7. [PMID: 22363114 PMCID: PMC3280393 DOI: 10.3748/wjg.v18.i6.491] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 04/15/2011] [Accepted: 04/22/2011] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS)-guided biliary drainage has emerged as a minimally invasive alternative to percutaneous and surgical interventions for patients with biliary obstruction who had failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-guided biliary drainage has become feasible due to the development of large channel curvilinear therapeutic echo-endoscopes and the use of real-time ultrasound and fluoroscopy imaging in addition to standard ERCP devices and techniques. EUS-guided biliary drainage is an attractive option because of its minimally invasive, single step procedure which provides internal biliary decompression. Multiple investigators have reported high success and low complication rates. Unfortunately, high quality prospective data are still lacking. We provide detailed review of the use of EUS for biliary drainage from the perspective of practicing endoscopists with specific focus on the technical aspects of the procedure.
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Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla. Gastrointest Endosc 2012; 75:56-64. [PMID: 22018554 DOI: 10.1016/j.gie.2011.08.032] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 08/15/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND ERCP may be challenging or may fail in certain situations, including postsurgical anatomy, periampullary diverticula, ampullary tumor invasion, and high-grade strictures. OBJECTIVE To report a large experience with EUS-guided anterograde cholangiopancreatography (EACP) to facilitate ductal access or perform direct EUS-guided therapy in patients with postsurgical anatomy or failed ERCP. DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS Ninety-five consecutive patients with failed ERCP or inaccessible papilla over a 4-year period. INTERVENTIONS EACP techniques involved ductal puncture and ductography, followed by either guidewire advancement for rendezvous ERCP in patients with duodenoscope accessible papilla or direct drainage in altered anatomy. For failures, crossover to the alternate EACP technique was performed when appropriate. MAIN OUTCOME MEASUREMENTS Technical success rates and complications. RESULTS EACP procedures were attempted in 95 of 2566 ERCP procedures (3.7%). EUS-guided cholangiography (n = 70) and pancreatography (n = 25) were successful in 97% and 100%, respectively. EUS-guided rendezvous ERCP was successful in 75% of biliary procedures and in 56% of pancreatic procedures. Direct EUS-guided therapy was successful in 86% and 75% of biliary and pancreatic procedures, respectively. Direct interventions included pancreaticogastrostomy (n = 10), anterograde stent across stricture (n = 10), hepaticogastrostomy (n = 8), and choledochoduodenostomy (n = 1). Ten complications (10.5%) related to EACP or subsequent rendezvous ERCP included pancreatitis (n = 5), hematoma (n = 1), bile leak (n = 1), bacteremia (n = 1), pneumoperitoneum (n = 1), and perforation (n = 1). LIMITATIONS Single-center experience; retrospective study. CONCLUSIONS EACP complements ERCP and allows successful pancreaticobiliary therapy in a large proportion of patients with failed ERCP or difficult-to-access papilla.
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Itoi T, Isayama H, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Tsuji S, Ishii K, Ikeuchi N, Tanaka R, Umeda J, Moriyasu F, Kawakami H. Stent selection and tips on placement technique of EUS-guided biliary drainage: transduodenal and transgastric stenting. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:664-72. [PMID: 21688214 DOI: 10.1007/s00534-011-0410-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been carried out as an alternative to the percutaneous or surgical approach when endoscopic retrograde cholangiopancreatography fails. However, there is no standard technique or device for EUS-BD. In this review, we focus on how we choose the stents and described our tips on this EUS-BD technique. The plastic stent (PS) and the self-expandable metallic stent (SEMS) are used for EUS-BD. The latter is further divided into the fully covered SEMS (FCSEMS), partially covered SEMS (PCSEMS), and uncovered SEMS (UCSEMS) types. Although PS is not expensive, the duration of stent patency is short. SEMS is expensive but the duration of stent patency is long. With UCSEMS, basically there is no stent malpositioning; however, if the gap between the bile duct and the GI tract becomes displaced, bile leakage from the mesh of the stent is likely to occur. Though there is no bile leakage with FCSEMS, the side branch of the bile duct may become occluded, and migration and dislocation sometimes occur. PCSEMS is basically similar to FCSEMS. When EUS-BD was first developed, drainage by PS was common, although reports on drainage by SEMS have increased recently.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjukuku, Tokyo, Japan.
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Itoi T, Kasuya K, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T, Ikeuchi N, Takeuchi M, Nagano T, Iwamoto H, Yamanouchi E, Shimazu M, Tsuchida A. Magnetic compression anastomosis for biliary obstruction: review and experience at Tokyo Medical University Hospital. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:357-65. [PMID: 21127913 DOI: 10.1007/s00534-010-0350-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Magnetic compression anastomosis (MCA) is a revolutionary, minimally invasive method of performing choledochoenterostomy or choledochocholedochostomy without using surgical techniques in patients with biliary stricture or obstruction. Herein, we describe a case series of MCA for severe biliary stricture or obstruction, which could not be treated with conventional therapies. PATIENTS AND METHODS Two patients with biliary obstruction were treated using MCA for choledochocholedochostomy and choledochoenterostomy at Tokyo Medical University Hospital and Tokyo Medical University Hachioji Medical Center. Endoscopically, a samarium-cobalt (Sm-Co) rare-earth magnet was placed at the superior site of obstruction through the percutaneous transhepatic biliary drainage route and another Sm-Co magnet was placed at the inferior site of obstruction. A comprehensive computer-aided literature search for MCA was performed up to September 2009 by using MEDLINE and EMBASE. RESULTS MCA techniques enabled complete anastomosis in both cases without procedure-related complications. CONCLUSIONS The MCA technique is a revolutionary method of performing choledochocholedochostomy and choledochoenterostomy interventionally in patients with biliary obstruction, for whom the conventional endoscopic procedure is not available, or in candidates who are deemed unsuitable for surgery.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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Artifon ELA, Okawa L, Takada J, Gupta K, Moura EGH, Sakai P. EUS-guided choledochoantrostomy: an alternative for biliary drainage in unresectable pancreatic cancer with duodenal invasion. Gastrointest Endosc 2011; 73:1317-20. [PMID: 21195404 DOI: 10.1016/j.gie.2010.10.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 10/25/2010] [Indexed: 12/11/2022]
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Kikuyama M, Itoi T, Ota Y, Matsumura K, Tsuchiya T, Itokawa F, Sofuni A, Yamao K. Therapeutic endoscopy for stenotic pancreatodigestive tract anastomosis after pancreatoduodenectomy (with videos). Gastrointest Endosc 2011; 73:376-82. [PMID: 21295649 DOI: 10.1016/j.gie.2010.10.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 10/10/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pancreatodigestive tract anastomotic site stenosis is a problematic complication after pancreatoduodenectomy. OBJECTIVE We evaluated the feasibility and efficacy of endoscopic treatments for a stenotic pancreatodigestive tract anastomosis. DESIGN Retrospective study. SETTING Endoscopic units of a university-affiliated hospital and a general hospital. PATIENTS Fourteen patients with recurrent pancreatitis (n=10) and pancreatic fluid fistula (n=4) after anatomy-altering surgery with pancreatodigestive tract anastomosis. INTERVENTIONS The initial ERCP included obtaining a pancreatogram, introducing a 0.025-inch guidewire through the anastomosis, along which a 5F plastic stent or nasopancreatic drain was inserted. If initial ERCP failed, we attempted EUS-guided rendezvous, with a guidewire passed antegrade from the main pancreatic duct across the stenotic anastomosis. MAIN OUTCOME MEASUREMENTS Rates of successful intervention and clinical relief. RESULTS The initial intervention was successfully achieved in 6 of 14 patients (38%). Of the 6 patients with successful therapeutic endoscopies, 4 (66.7%) and 2 (25.0%) had undergone a previous pancreatogastrostomy or pancreatojejunostomy, respectively. Eight patients with an initial unsuccessful intervention successfully underwent a second intervention using an EUS-guided or US-guided rendezvous method. Finally, stenosis was relieved in all patients with either the retrograde placement of a pancreatic duct stent across the stenosis of an anastomotic site or antegrade percutaneous bougienage of the stenotic anastomosis. LIMITATIONS Small sample size and lack of control patients. CONCLUSIONS Endoscopic treatment of stenotic pancreatodigestive tract anastomosis for transanastomotic pancreatic juice drainage is safe and feasible.
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Affiliation(s)
- Masataka Kikuyama
- Department of Gastroenterology, Shizuoka General Hospital, Shizuoka, Japan
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