Different options of endosonography-guided biliary drainage after endoscopic retrograde cholangio-pancreatography failure

Abstract

Aim: To investigate the success rates of endosonography (EUS)-guided biliary drainage (EUS-BD) techniques after endoscopic retrograde cholangiopancreatography (ERCP) failure for management of biliary obstruction.

Methods: From Feb/2010 to Dec/2016, ERCP was performed in 3538 patients, 24 of whom (0.68%) suffered failure to cannulate the biliary tree. All of these patients were initially submitted to EUS-guided rendez-vous (EUS-RV) by means of a transhepatic approach. In case of failure, the next approach was an EUS-guided anterograde stent insertion (EUS-ASI) or an EUS-guided hepaticogastrostomy (EUS-HG). If a transhepatic approach was not possible or a guidewire could not be passed through the papilla, EUS-guided choledochoduodenostomy (EUS-CD) was performed.

Results: Patients were submitted to EUS-RV (7), EUS-ASI (5), EUS-HG (6), and EUS-CD (6). Success rates did not differ among the various EUS-BD techniques. Overall, technical and clinical success rates were 83.3% and 75%, respectively. Technical success for each technique was, 71.4%, 100%, 83.3%, and 83.3%, respectively (P = 0.81). Complications occurred in 3 (12.5%) patients. All of these cases were managed conservatively, but one patient died after rescue percutaneous transhepatic biliary drainage (PTBD).

Conclusion: The choice of a particular EUS-BD technique should be based on patient's anatomy and on whether the guidewire could be passed through the duodenal papilla.

Keywords: Cholestasis; Drainage; Endosonography; Interventional procedures; Jaundice; Neoplasms.

Figure 1

The systematic endosonography-guided biliary drainage approach for endoscopic retrograde cholangiopancreatography failure. PTBD: Percutaneous transhepatic biliary drainage; EUS-CD: Endosonography-guided choledochoduodenostomy; EUS-HG: Endosonography-guided hepaticogastrostomy; EUS-ASI: Endosonography-guided anterograde stent insertion; EUS-RV: Endosonography-guided rendez-vous.

Figure 2

Patient with acute pancreatitis after cholecystectomy and Billroth II gastrectomy. Endosonography (EUS)-guided rendez-vous technique. A: EUS image with dilation of the intrahepatic biliary duct; B: EUS-guided cholangiography; C: Insertion of the guidewire across the duodenal papilla and positioning in the duodenum; D: Capture of the guidewire with a frontal view endoscope; E: Balloon dilatation of the duodenal papilla; F: Insertion of a 10 Fr plastic stent.

Figure 3

Patient with duodenal stenosis due to a pancreatic carcinoma. A: Endosonography (EUS)-guided cholangiography; B: Insertion of the guidewire through the duodenal major papilla and positioning in the duodenum; C: Anterograde insertion of the self-expandable metallic stents (SEMS) through the gastric wall across the duodenal major papilla and its positioning in the duodenum; D: Deployment of the SEMS; E: Insertion of the duodenal SEMS. SEMS: Self-expandable metallic stents.

Figure 4

Endosonography-guided hepatogastrostomy. A: Endosonography (EUS) puncture of the dilated biliary intrahepatic duct; B: EUS-guided cholangiography; C and D: Deployment and positioning of the biliary self-expandable metallic stents (SEMS); E: Endoscopic view of the SEMS through the gastric wall.

Figure 5

Endosonography-guided choledochoduodenostomy. A: Endosonography (EUS) image of the pancreatic carcinoma; B: Puncture of the common bile duct through the duodenum with a 19 gauge aspiration needle; C: Insertion of the self-expandable metallic stents after balloon dilation of the fistula; D: EUS-guided cholangiography through the choledochoduodenostomy.