EUS-guided biliary drainage for patients with malignant biliary obstruction with an indwelling duodenal stent (with videos)

Abstract

Endoscopic retrograde cholangiography (ERC) is the method most commonly used for palliation of malignant biliary obstruction. Percutaneous and, rarely, surgical bypass are used after failed ERC. EUS-guided biliary drainage (EGBD) is an emerging less-invasive alternative after unsuccessful transpapillary biliary cannulation in patients with altered anatomy (eg, pancreaticoduodenectomy) and those with gastric outlet obstruction. 1 Voegeli D.R. Crummy A.B. Wesse J.L. Percutaneous transhepatic cholangiography, drainage, and biopsy in patients with malignant biliary obstruction An alternative to surgery. Am J Surg. 1985; 150: 243-247 Abstract Full Text PDF PubMed Scopus (32) Google Scholar , 2 Oh H.C. Lee S.K. Lee T.Y. et al. Analysis of percutaneous transhepatic cholangioscopy-related complications and the risk factors for those complications. Endoscopy. 2007; 39: 731-736 Crossref PubMed Scopus (112) Google Scholar EGBD can be performed entirely transhepatically or transduodenally without accessing the papilla or via rendezvous whereby the guidewire must pass through the papilla. Patients with gastric outlet obstruction resulting from duodenal tumor compression and/or infiltration present a particular challenge during ERC, especially in the presence of a duodenal self-expandable metal stent (SEMS). Although ERC can be accomplished by fenestration of a duodenal stent in some cases, 3 Topazian M. Baron T.H. Endoscopic fenestration of duodenal stents using argon plasma to facilitate ERCP. Gastrointest Endosc. 2009; 69: 166-169 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar alternative approaches for biliary access and drainage are needed when the papilla is unable to be reached or visualized. 4 Mutignani M. Tringali A. Shah S.G. et al. Combined endoscopic stent insertion in malignant biliary and duodneal obstruction. Endoscopy. 2007; 39: 440-447 Crossref PubMed Scopus (137) Google Scholar , 5 Baron T.H. Management of simultaneous biliary and duodenal obstruction: the endoscopic perspective. Gut Liver. 2010; 4: S50-S56 Crossref PubMed Scopus (25) Google Scholar Transpapillary versus transmural biliary drainage in patients with an indwelling duodenal stent: when is one indicated over the other?Gastrointestinal EndoscopyVol. 77Issue 4PreviewWe read with great interest the article by Khashab et al1 on a case-series study of biliary self-expandable metal stent (SEMS) placement in the presence of a duodenal SEMS. In their study, biliary drainage was obtained mostly by transpapillary SEMS via EUS-guided techniques, and they demonstrated considerably high rates of technical and short-term clinical success. Full-Text PDF