EUS-guided intrahepatic biliary drainage: a large retrospective series and subgroup comparison between percutaneous drainage in hilar stenoses or postsurgical anatomy

Abstract

Background and study aims Endoscopic ultrasound-guided intrahepatic biliary drainage (EUS-IBD) struggles to find a place in management algorithms, especially compared to percutaneous drainage (PTBD). In the setting of hilar stenoses or postsurgical anatomy data are even more limited. Patients and methods All consecutive EUS-IBDs performed in our tertiary referral center between 2012 - 2019 were retrospectively evaluated. Rendez-vous (RVs), antegrade stenting (AS) and hepatico-gastrostomies (HGs) were compared. The predefined subgroup of EUS-IBD patients with proximal stenosis/surgically-altered anatomy was matched 1:1 with PTBD performed for the same indications. Efficacy, safety and events during follow-up were compared. Results One hundred four EUS-IBDs were included (malignancies = 87.7 %). These consisted of 16 RVs, 43 ASs and 45 HGs. Technical and clinical success rates were 89.4 % and 96.2 %, respectively. Any-degree, severe and fatal adverse events (AEs) occurred in 23.3 %, 2.9 %, and 0.9 % respectively. Benign indications were more common among RVs while proximal stenoses, surgically-altered anatomy, and disconnected left ductal system among HGs. Procedures were shorter with HGs performed with specifically designed stents (25 vs . 48 minutes, P = 0.004) and there was also a trend toward less dysfunction with those stents (6.7 % vs . 30 %, P = 0.09) compared with previous approaches. Among patients with proximal stenosis/surgically-altered anatomy, EUS-IBD vs. PTBD showed higher rates of clinical success (97.4 % vs. 79.5 %, P = 0.01), reduced post-procedural pain (17.8 % vs. 44.4 %, p = 0.004), shorter median hospital stay (7.5 vs 11.5 days, P = 0.01), lower rates of stent dysfunction (15.8 % vs. 42.9 %, P = 0.01), and the mean number of reinterventions was lower (0.4 vs. 2.8, P < 0.0001). Conclusions EUS-IBD has high technical and clinical success with an acceptable safety profile. HGs show comparable outcomes, which are likely to further improve with dedicated tools. For proximal strictures and surgically-altered anatomy, EUS-IBD seems superior to PTBD.

Fig. 1

Selection of patients. Between January 2012 and October 2019, 104 EUS-IBDs were performed. After transgastric intrahepatic access, e-RV was performed in 16 patients (15.4 %), e-AS in 43 (43.3 %) and e-HG in 45 (41.3 %). Outcomes of these three techniques were compared. We then identified EUS-IBDs performed for hilar/intrahepatic stenosis or in the setting of postsurgical anatomy. These procedures were matched to one PTBD case from an historical cohort of PTBDs executed in the same time frame, using the criteria described in the text. Finally, outcomes of 45 EUS-IBDs and 45 PTBD were compared.

Fig. 2

Endoscopic and percutaneous procedures described in this paper. Top: procedures following EUS-guided intrahepatic access. a EUS-guided rendez-vous (e-RV) when EUS-IBD was used to allow antegrade transpapillary placement of a guidewire used for final retrograde therapeutic procedure (cannulation over or next to the guidewire). b EUS-guided antegrade stenting (e-AS) when a metal stent was advanced transgastric and transhepatic over a guidewire and finally placed bypassing a stenosis. c EUS-guided hepatico-gastrostomies (e-HG) when the drainage was guaranteed through the placement of a self-expanding metal stent (SEMS) between the left intrahepatic duct and the stomach. Bottom: Percutaneous procedures. d Percutaneous external drainage (p-ED) when the stenosis could not be passed and drainage was obtained through a transhepatic externally-placed catheter connected to a drainage bag. e Percutaneous external/internal drainage (p-EID) when a drainage was placed with an external trans-cutaneous tip and an internal transpapillary tip in the duodenum. f Percutaneous antegrade stenting (p-AS) when a metal stent was advanced transhepatic and finally placed bypassing a stenosis.

Fig. 3

Hepaticogastrostomy. a Transgastric EUS-guided puncture of a dilated duct of left liver lobe. b Contrast injection and guidewire cannulation of the biliary tree. c After tract consolidation through cystotome, placement of a partially-covered SEMS with an uncovered portion for intrahepatic placement and a covered portion crossing the liver parenchyma and ending in the gastric lumen. d Endoscopic appearance of the covered part of the SEMS inside the gastric lumen.

Fig. 4

Proposed algorithm for the management of biliary obstruction. In case of postsurgical anatomy, when papillary region is not accessible, EUS-guided intrahepatic biliary drainage (EUS-IBD) may represent the first-line treatment modality. In case of biliary stenosis and failed ERCP: 1) when stenosis is distal and the common bile duct is significantly dilated we propose extrahepatic drainage through an electrocautery-enhanced LAMS as the first-line treatment; 2) when the stenosis is proximal and determines a dilation of the left biliary tree we propose EUS-IBD as the first-line treatment; and 3) when the stenosis determines an isolated dilation of the right biliary tree (or other modalities have failed) we propose percutaneous biliary drainage (PTBD). *The cut-off included in the algorithm is taken from studies cited in the text, but may vary according to specific cases and local expertise. ^# Post-surgical anatomy impeding access to papillary area (e. g. pancreaticoduodenectomy), with the exception of Roux-en-Y gastric bypass.