The Efficacy of Endoscopic Ultrasound Guided Choledochoduodenostomy (EUS-CDS) in Five Cases of Obstructive Jaundice Caused by Ampullary or Lower Biliary Duct Obstruction with a Special Reference to Stent Patency

Abstract

Background and Study Aims: Endoscopic biliary drainage may be unsuccessful in some patients. The alternative method of percutaneous transhepatic biliary drainage (PTBD) has a risk of complications. Recently, endoscopic ultrasound (EUS) guided biliary stent placement has been described in patients with malignant biliary obstruction. We described our 5 cases-experience of EUS guided biliary drainage from the first portion of the duodenum with a special reference to stent patency. Patients: Five patients who underwent EUS-CDS from the first portion of the duodenum from 2003 to 2005 were analyzed. The sex ratio of the patients was 3:2 and the mean average age was 78 year old with a range of 61 and 83. The patients consisted of three cases of pancreatic head cancer and two cases of ampulla of Vater cancer. Method: Informed consent from 5 patients was obtained for EUS-CDS. Using a convex linear array echoendoscope the markedly dilated extra-hepatic bile duct was visualized at the level of the duodenal bulb. EUS-guided puncture of the dilated extra-hepatic bile duct was performed with the needle knife, and then exchanged the guide wires (0.035 inch, 450 cm). Tapered biliary dilator catheters of 7 French and 9 French in size were inserted and removed in order to dilate the tract over the guidewire. Finally, an 8.5 Fr. straight biliary stent was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. When the stent was occluded during the follow-up period, it was removed by duodenoscopy using a basket catheter. A guide wire (0.035 inch, 450 cm) through the ERCP catheter was inserted deeply from the choledochoduodenal fistula into the intrahepatic biliary ducts under fluoroscopy. A new stent an 8.5 Fr. straight biliary stent, was inserted over the guide wire. Finally, the guide wire was removed. Results: Stent insertion was technically successful in all 5 patients. The procedure was also clinically effective in relieving jaundice in all cases. One patient developed pneumoperitoneum one day after procedure, which resolved conservatively with fasting and antibiotics in few days. Early stent occlusion occurred in two patients after 2 and 4 weeks, respectively, which made a repeat procedure with stent exchange easily. Average patency of the stents reached more than 180 days, 95% C.I. (111-249). Conclusion: EUS-CDS from first portion of the duodenum is a feasible and safe, and become alternative to PTBD for drainage of obstructed biliary system, in the future.