Informed Consent for Endoscopic Biliary Drainage: Time for a New Paradigm.

Marco Spadaccini,Luigi Cugia,Cecilia Binda,Alessandro Fugazza,Ilaria Tarantino,Andrea Anderloni,Carlo Fabbri,Alessandro Repici

doi:10.3390/medicina58030331

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is considered as the first option in the management of malignant biliary obstruction. In case of ERCP failure, percutaneous transhepatic biliary drainage (PTBD) has been conventionally considered as the preferred rescue strategy. However, the use of endoscopic ultrasound (EUS) for biliary drainage (EUS-BD) has proved similarly high rates of technical success, when compared to PTBD. As a matter of fact, biliary drainage is maybe the most evident paradigm of the increasing interconnection between ERCP and EUS, and obtaining an adequate informed consent (IC) is an emerging issue. The aim of this commentary is to discuss the reciprocal roles of ERCP and EUS for malignant biliary obstruction, in order to provide a guide to help in developing an appropriate informed consent reflecting the new biliopancreatic paradigm.

Highlights

Endoscopic retrograde cholangiopancreatography (ERCP) is considered as the first option in the management of malignant biliary obstruction, with rates of successful deep cannulation ranging from 89% to 92% using conventional techniques [1,2,3]
Obtaining an adequate informed consent (IC) is for sure one of those aspects. This troublesome, but underestimated issue, is often taken for granted, even if remaining a fundamental legal and ethical principle before any procedures. The aim of this commentary is to discuss the reciprocal roles of ERCP and endoscopic ultrasound (EUS) for malignant biliary obstruction, in order to provide a guide to help in developing an appropriate informed consent reflecting the new biliopancreatic paradigm
Why should we not widen those borders? Who fixed them? After all, if we look deep into it, choledocoduodenostomy could be considered as an EUS-guided pre-cut differing from what we are used to do with a needle knife by a couple of centimeters and, possibly, by the type of the stent

Summary

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is considered as the first option in the management of malignant biliary obstruction, with rates of successful deep cannulation ranging from 89% to 92% using conventional techniques [1,2,3]. The significant rate of adverse events (i.e., tube dislodgement/occlusion, cholangitis) significantly contribute to reducing the quality of life of our patients [8,9] In this regard, endoscopic ultrasound (EUS) for biliary drainage (EUS-BD) was first performed in 2001 by Giovannini et al [10] and, since it has shown rates of technical success comparable to PTBD. This troublesome, but underestimated issue, is often taken for granted, even if remaining a fundamental legal and ethical principle before any (endoscopic) procedures The aim of this commentary is to discuss the reciprocal roles of ERCP and EUS for malignant biliary obstruction, in order to provide a guide to help in developing an appropriate informed consent reflecting the new biliopancreatic paradigm

From General Principles to Our Starting Point

EUS-Guided Rendezvous

EUS-Guided Choledochoduodenostomy

EUS-Guided Hepaticogastrostomy

Findings

EUS-Guided Gallbladder Drainage