Combined EUS and ERCP for Distal Biliary Obstruction: Technical Feasibility, Success Rates of Biliary Decompression and Tissue Sampling

Abstract

Background: While endoscopic ultrasound (EUS) and ERCP are commonly performed procedures in the evaluation and management of presumed malignant biliary obstruction, there is a paucity of literature describing the use of combined procedures. Methods: We retrospectively reviewed all EUS and ERCP performed on the same day between 7/02-7/06. EUS with a pre-procedure indication of a biliary stricture or suspected mass in the head of the pancreas were evaluated. The indication of the ERCP was jaundice or increased liver enzymes. Exclusion criteria included: choledocholithiasis, pancreatic cyst management, prior sphincterotomy, prior biliary or pancreatic stents, non-visualized papilla due to tumor in-growth, hilar strictures, known or presumed PSC, and surgically altered anatomy. For a comparison, ERCP done alone over the same time period with the same indications and exclusion criteria were reviewed. Data extracted included medication use, technical success of placing a biliary stent, and the results of all tissue sampling. All pathology specimens were reported as malignant, suspicious, atypical, or benign. Results: Fifty-three combination procedures (EUS/ERCP) and 124 ERCP met the study criteria. The mean midazolam dose was higher in the EUS/ERCP group than in the ERCP alone group (6.36 mg vs. 5.53 mg, p = 0.0086). The mean fentanyl equivalent dose (fentanyl 100 mcg = merperidine 75 mg) was also higher in the EUS/ERCP group (219.1 mcg vs. 192.9 mcg, p = 0.029). There was no difference in the use of an adjuvant medication (i.e. droperidol, promethazine, diphenhydramine) between the groups (42.7% vs. 50.9%, p = 0.3). Successful cannulation and stent placement was achieved in 52/53 in the EUS/ERCP group and 118/124 in the ERCP group (98.1% vs. 95.2%, p = 0.3). Tissue sampling was performed more often in the EUS/ERCP group than the ERCP group (94.3% vs. 63.7%, p < 0.001). There were no significant differences in the percentage of studies in which biliary brushings (56.6% vs. 62.9%, p = 0.4) or forceps biopsies were obtained (17.0% vs. 12.1%, p = 0.3). EUS/FNA was performed in 56.6%. Combining all tissue sampling techniques, the EUS/ERCP group more often achieved a definitively malignant pathology result as compared to the ERCP group (70% vs 32.9%, p < 0.001). Conclusion: Same day EUS/ERCP with moderate sedation for presumed malignant distal bile duct obstruction appears technically feasible. If pathologic specimens are taken, a combined procedure results in a higher yield of definitively positive results, specifically due to the ability to perform FNA. Combined procedures require minimal added sedation and do not limit the ability to drain an obstructed biliary system.