Optimal biliary access point and learning curve for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting

Abstract

Background: Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) with transmural stenting has increased for biliary decompression in patients with an inaccessible papilla, the optimal biliary access point and the learning curve of EUS-HGS have not been studied. We evaluated the optimal biliary access point and learning curve for technically successful EUS-HGS.

Methods: 129 consecutive patients (male n = 81, 62.3%; malignant n = 113, 87.6%) who underwent EUS-HGS due to an inaccessible papilla were enrolled. EUS finding and procedure times according to each needle puncture attempt in EUS-HGS were prospectively measured. Learning curves of EUS-HGS were calculated for two main outcome measurements (procedure time and adverse events) by using the moving average method and cumulative sum (CUSUM) analysis, respectively.

Results: A total of 174 EUS-HGS attempts were performed in 129 patients. The mean number of needle punctures was 1.35 ± 0.57. Using the logistic regression model, bile duct diameter of the puncture site ⩽ 5 mm [odds ratio (OR) 3.7, 95% confidence interval (CI): 1.71-8.1, p < 0.01] and hepatic portion length [linear distance from the mural wall to the punctured bile duct wall on EUS; mean hepatic portion length was 27 mm (range 10-47 mm)] > 3 cm (OR 5.7, 95% CI: 2.7-12, p < 0.01) were associated with low technical success. Procedure time and adverse events were shorter after 24 cases, and stabilized at 33 cases of EUS-HGS, respectively.

Conclusions: Our data suggest that a bile duct diameter > 5 mm and hepatic portion length 1 cm to ⩽ 3 cm on EUS may be suitable for successful EUS-HGS. In our learning curve analysis, over 33 cases might be required to achieve the plateau phase for successful EUS-HGS.

Keywords: biliary obstruction; endoscopic ultrasound; endoscopic ultrasound-guided biliary drainage; learning curve.

Figure 1.

Flow diagram for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting. EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting.

Figure 2.

Time taken to perform ultrasound-guided hepaticogastrostomy with transmural stenting as a function of the number of cases. The moving-average method was used to determine changes in procedure time.

Figure 3.

The adverse events for ultrasound-guided hepaticogastrostomy with transmural stenting as a function of the number of cases. CUSUM, cumulative sum. The CUSUM analysis was used to determine changes in adverse event rates.

Figure 4.

A case of endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting. (a) The intrahepatic bile duct diameter was 4.7 mm on endoscopic ultrasound. (b) Endoscopic ultrasound-guided puncture was performed. The linear distance from the mural wall to the punctured bile duct wall was more than 3 cm in the measurement of EUS. (c) Failed biliary opacification was demonstrated on fluoroscopy at the first attempt. (d) Misplacement of the guidewire was also demonstrated on fluoroscopy at the second attempt. (e, f) Reposition of endoscopic ultrasound FNA needle for better access to the transmural stenting was performed. The distance from the mural wall to the punctured bile duct was ⩽ 3 cm. (g) The guidewire was introduced through the endoscopic ultrasound needle and advanced into the bile duct. Then a fully covered metal stent was successfully placed at the third attempt. EUS, endoscopic ultrasound; FNA, fine-needle aspiration needle.