Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography

Abstract

Endoscopic ultrasonography (EUS)-guided biliary drainage was performed for treatment of patients who have obstructive jaundice in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). In the present study, we introduced the feasibility and outcome of EUS-guided choledochoduodenostomy in four patients who failed in ERCP. We performed the procedure in 2 papilla of Vater, including one resectable case, and 2 cases of cancer of the head of pancreas. Using a curved linear array echoendoscope, a 19 G needle or a needle knife was punctured transduodenally into the bile duct under EUS visualization. Using a biliary catheter for dilation, or papillary balloon dilator, a 7-Fr plastic stent was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. In 3 (75%) of 4 cases, an indwelling plastic stent was placed, and in one case in which the stent could not be advanced into the bile duct, a naso-biliary drainage tube was placed instead. In all cases, the obstructive jaundice rapidly improved after the procedure. Focal peritonitis and bleeding not requiring blood transfusion was seen in one case. In this case, pancreatoduodenectomy was performed and the surgical findings revealed severe adhesion around the choledochoduodenostomy site. Although further studies and development of devices are mandatory, EUS-guided choledochoduodenostomy appears to be an effective alternative to ERCP in selected cases.

Figure 1

Convex echoendoscope clearly depicts the extrahepatic bile duct (green) (patient 3). GB: Gallbladder; CBD: Common bile duct; PV: Portal vein.

Figure 2

After EUS-guided puncture, contrast medium is injected into the bile duct for cholangiogram, a 0.035-inch guidewire was inserted into the outer sheath (patient 3).

Figure 3

A: Choledochoduodenostomy was accomplished with a 7-Fr plastic stent in the apex of the duodenal bulb (patient 3); B: The stent was visible in the duodenal bulb (patient 3).

Figure 4

Choledochoduodenostomy was accomplished using a 5-Fr naso-biliary tube (patient 2).

Figure 5

A: Macroscopic view of completed choledochoduodenostomy (patient 2); B: Surgical specimens showing the completed choledochoduodenostomy with mild inflammatory cell infiltrate adjacent to the sinus tract in the duodenal and bile duct walls (HE, × 20, patient 2); C: Magnification of bile duct site (HE, × 100, patient 2); D: Magnification of bile duct site (HE, × 100, patient 2). BD: Bile duct.