Endoscopic Biliary Drainage Research Articles

Endoscopy Ultrasound-Guided Biliary Drainage Using Lumen Apposing Metal Stent in Malignant Biliary Obstruction.

This narrative review provides an overview of the application of endoscopic ultrasound-guided biliary drainage (EUS-BD), including EUS-guided gallbladder drainage (EUS-GBD), for the treatment of malignant biliary obstruction. EUS-BD has demonstrated excellent technical and clinical success rates, with lower rates of adverse events when compared with percutaneous trans-hepatic biliary drainage (PTBD). EUS-BD is currently the preferred alternative technique for biliary drainage (BD) in patients with distal malignant biliary obstruction (DMBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Particularly, this review will focus on EUS-BD performed with the use of lumen apposing metal stent (LAMS). The introduction of these innovative devices, followed by the advent of electrocautery-enhanced LAMS (EC-LAMS), gave the procedure a great technical implementation and a widespread application.

Endoscopic Ultrasonography-Guided Biliary Drainage: Experience of a Moroccan Center

Background: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new therapeutic modality in the arsenal of endoscopists for attaining satisfactory biliary drainage when traditional ERC fails. The aim of our study is to describe the first Moroccan experience with EUS-BD in patients with malignant biliary obstruction after a failed or inaccessible ERCP. Methods: This is a retrospective study conducted at Ibn Sina Hospital, from Mars 2018 to July 2022, which include 27 patients with an inoperable or metastatic malignant biliary obstruction who underwent endoscopic ultrasonography-guided biliary drainage (EUS-BD) in case of endoscopic retrograde cholangiopancreatography (ERCP) failure. Results: From a total of 288 patients with malignant biliary obstruction,27 underwent EUS-BD (9,3%), 15 EUS-guided hepaticogastrostomy (55,5%) and 12 EUS-guided choledocoduodenostomy (44,4%) were performed. The mean age was 62.5 years (age range: 23-74 years), a male predominance of 59% was noted, cholestatic jaundice was present in 100% of patients and associated with pruritus in 92.59% of cases. The mean level of Total Bilirubin was 190 mg/l. The causes of biliary obstruction were: an inoperable pancreatic head mass in 13 patients(48,1%), a cholangiocarcinoma in 7 patients (25.9%), an ampullary mass in 4 patients(14,8%), a gallbladder cancer with hepatic and duodenal invasion in one patient (3,7%), a gastric antropyloric adenocarcinoma with pancreatic head invasion in one patient (3,7%) and Duodenal adenocarcinoma in one patient (3,7%).The leading causes of failed ERCP were secondary to tumor infiltration of the duodenal wall and critical duodenal stenosis in 11 cases (40,7%), in 9 cases due to a difficult cannulation (33.3%) and in 7 cases due to a failure to pass the stricture by ERCP (25.9%). In EUS-HG The technical and the clinical success rates were 86.6% (13/15) and 84.6% (11/13), respectively, the complication rate was 13.3% (2/15) including one case of stent migration complicated with bile leak and one case of cholangitis. In EUS-CD The technical and the clinical success rates were 91.6% (11/12) and 81.8% (9/11)), respectively, the complication rate was 16.6% (2/12) including two cases of cholangitis. The technical and the clinical success rates in all EUS-BD were 85.1% (24/27) and 83.3% (20/24), respectively. The complication rate was 14.8% (4/27). Conclusion: EUS-BD appears to be an effective and safe therapeutic option for biliary decompression in cases where ERCP fails.

Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial)

Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M). In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles. From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P= .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted. Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO. gov, Number: NCT03870386.

Endoscopic Ultrasound-guided Versus Percutaneous Transhepatic Biliary Drainage After Failed ERCP: A Systematic Review and Meta-analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) may fail to achieve biliary drainage in 5% to 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) are alternative therapeutic options in such cases. The present meta-analysis aimed to compare the efficacy and safety of EUS-BD and PTBD for biliary decompression after failed ERCP. A comprehensive search of literature from inception to September 2022 was done of 3 databases for studies comparing EUS-BD and PTBD for biliary drainage after failed ERCP. Odds ratios (ORs) with 95% CIs were calculated for all the dichotomous outcomes. Continuous variables were analyzed using mean difference (MD). A total of 24 studies were included in the final analysis. Technical success was comparable between EUS-BD and PTBD (OR=1.12, 0.67-1.88). EUS-BD was associated with a higher clinical success rate (OR=2.55, 1.63-4.56) and lower odds of adverse events (OR=0.41, 0.29-0.59) compared with PTBD. The incidence of major adverse events (OR=0.66, 0.31-1.42) and procedure-related mortality (OR=0.43, 0.17-1.11) were similar between the groups. EUS-BD was associated with lower odds of reintervention with an OR of 0.20 (0.10-0.38). The duration of hospitalization (MD: -4.89, -7.73 to -2.05) and total treatment cost (MD: -1355.46, -2029.75 to -681.17) were significantly lower with EUS-BD. EUS-BD may be preferred over PTBD in patients with biliary obstruction after failed ERCP where appropriate expertise is available. Further trials are required to validate the findings of the study.

Pancreatic ductal adenocarcinoma arising from the pancreatic parenchyma compressed by a huge pancreatic lipoma: a case report

BackgroundPancreatic lipomas (PLs) arising from the adipose tissue in the pancreatic parenchyma are rare among pancreatic tumors. Coexisting pancreatic ductal adenocarcinoma (PDAC) and PLs have not been previously reported. Herein, we report a case of PDAC arising from the pancreatic parenchyma with chronic pancreatitis compressed by a large PL.Case presentationThe patient was a 69-year-old male. He had been diagnosed with a PL using computed tomography (CT) 12 years previously. The tumor had been slowly growing and was followed up carefully because of the possibility of well-differentiated liposarcoma. During follow-up, laboratory data revealed liver damage and slightly elevated levels of inflammatory markers. Contrast-enhanced CT revealed the previously diagnosed 12 cm pancreatic head tumor and an irregular isodensity mass at the upper margin of the tumor that invaded and obstructed the distal common bile duct. Magnetic resonance cholangiopancreatography demonstrated no specific findings in the main pancreatic duct. Based on these imaging findings, the patient underwent endoscopic retrograde biliary drainage and bile duct brushing cytology, which revealed indeterminate findings. The differential diagnosis of the tumor at that time was as follows: (1) pancreatic liposarcoma (focal change from well-differentiated to dedifferentiated, not lipoma), (2) distal cholangiocarcinoma, and (3) pancreatic cancer. After the cholangitis improved, a pancreatoduodenectomy was performed. Histologically, hematoxylin–eosin staining revealed moderately differentiated PDAC compressed by proliferating adipose tissue. The adipose lesion showed homogeneous adipose tissue with no evidence of sarcoma, which led to a diagnosis of lipoma. Additionally, extensive fibrosis of the pancreatic parenchyma and atrophy of the acinar cells around the lipoma was suggestive of chronic pancreatitis. The pathological diagnosis was PDAC (pT2N0M0 pStage Ib) with chronic pancreatitis and PL. The postoperative course was uneventful, and the patient was discharged on the 15th day after surgery. The patient received adjuvant chemotherapy and has remained recurrence-free for more than 6 months.ConclusionsPL may be associated with the development of PDAC in the surrounding inflammatory microenvironment of chronic pancreatitis. In cases of growing lipomas, careful radiologic surveillance may be needed not only for the possibility of liposarcoma but also for the coincidental occurrence of PDAC.

Endoscopic reintervention after unilateral metal stent deployment for MHBO using SIS method.

Endoscopic biliary drainage is the main treatment for unresectable malignant hilar biliary obstruction (MHBO). Recurrent biliary obstruction (RBO) often occurs after unilateral metal stent deployment. Endoscopic reintervention can be complex for this problem, especially for drainage of the contralateral bile duct. The stent-in-stent (SIS) method is a possible solution to this problem. Our objective was to evaluate the safety and feasibility of the SIS method for endoscopic reintervention in patients with RBO due to MHBO after unilateral metal stent deployment. Eleven patients with MHBO received endoscopic reintervention using the SIS method to manage RBO after unilateral metal stent deployment. Clinical data, including technical and clinical success, procedure time, adverse events and complications, stent patency, RBO of the revisionary stent, and survival time were recorded. Nine patients (82%) achieved technical success, and all 9 of them also achieved clinical success. The 2 unsuccessful cases received percutaneous transhepatic cholangial drainage. The median procedure time was 73 minutes. The 3 adverse events were post-endoscopic retrograde cholangiopancreatography pancreatitis, cholangitis, and liver abscess. 6 patients (67%) experienced RBO of the revisionary stent, the median time to RBO of the revisionary stent was 95.5 days, the median survival time after reintervention was 111 days, and the median overall survival time was 305.5 days. Endoscopic reintervention after previous unilateral metal stent deployment using the SIS method appears to be safe and technically feasible for MHBO patients who experience RBO.

Comparable Efficacy of Laser-Cut and Braided Self Expanding Metallic Biliary Stent: A Systematic Review and Meta-Analysis.

In patients with unresectable malignant biliary obstruction (MBO), endoscopic biliary drainage is the treatment of choice. Self-expanding metallic stents (SEMS) are mainly used for this purpose, and data is limited on the comparative outcomes of laser-cut versus braided SEMS. Herein, we performed the first systematic review and meta-analysis to study the effectiveness and safety of braided and laser-cut SEMS in MBO. Multiple databases, including Medline, Scopus, and Embase, were searched (in May 2022) using specific terms for studies evaluating the outcomes of braided and laser-cut SEMS in MBO. Outcomes of interest were technical and clinical success, recurrent biliary obstruction, and adverse events. Standard meta-analysis methods were employed using the random-effects model. I2% heterogeneity was used to assess the heterogeneity. Seven studies were included in the final analysis. (Laser-cut: 271 patients, 46% females, mean age 70years; and braided: 282 patients, 47% females, mean age 72years). The pooled rate of technical success and clinical success with laser-cut SEMS was 99% (95% CI [95-99; I2 = 0%]), 86% [60-96; I2 = 74%], and 98% [96-99; I2 = 0%], 89% [74-95; I2 = 78%] with braided. The pooled rate of recurrent biliary obstruction with laser-cut SEMS was 26% [14-43; I2 = 88%] and 12% [5-27; I2 = 56%) with braided. Pooled total adverse events were 11% [5-21; I2 = 77%] in laser-cut and 12% [6-24; I2 = 63%] in braided. Our meta-analysis demonstrates similar clinical outcomes with laser-cut and braided SEMS in MBO. Given the comparable performance, a cost-effectiveness analysis might help in choosing one type versus another in patients with MBO.

Billiary Tract Obstruction due to Gallbladder Carcinoma at Prof. Dr. R. D. Kandou General Hospital: Two Case Reports

Abstract: Gallbladder cancer is the fifth most common gastrointestinal malignancy with a high mortality rate. Detection of gallbladder carcinoma in early stages can be difficult, despite improvements in ultrasound and CT-Scan imaging. It is possible to cure gallbladder cancer surgically at an early stage. We reported two cases of gall bladder carcinoma, 65-year-old and 52-year-old females, with the chief complaints of abdominal pain in the right upper quadrant (RUQ) and obstructive jaundice in both cases. The abdominal CT-scans showed circumferentially irregular focal thickening of gallbladder wall, and severe intra and extrahepatic cholestasis. Endoscopic preoperative biliary drainage using biliary stent was performed in one case. Open cholecystectomy with in toto common bile duct resection and portal lymphadenectomy followed by roux en-y hepaticojejunostomy reconstruction were performed for both cases. Both patients are still well with no cancer recurrences over two-year follow-up. The symptoms of gall bladder cancer were non-specific, and commonly included RUQ abdominal pain, weight loss, anorexia, nausea or vomiting, jaundice, and pruritus. Imaging with ultrasound and CT-Scan had improved preoperative diagnosis of gallbladder cancer. Outcomes of patient with incidental finding of gallbladder cancer had better prognosis since it provided the patient to be staged and managed appropriately with resection. In conclusion, early detection of gallbladder cancer results in better surgical outcome and less patient morbidity and mortality which shows its importance. Keywords: gallbladder carcinoma; early-stage detection; common bile duct resection

Endoscopic ultrasound-guided gallbladder drainage as a first approach for jaundice palliation in unresectable malignant distal biliary obstruction: Prospective study.

Endoscopic retrograde cholangiopancreatography (ERCP) represents the gold standard for jaundice palliation in patients with distal malignant biliary obstruction (DMBO). Biliary drainage using electrocautery lumen apposing metal stent (EC-LAMS) is currently a well-established procedure when ERCP fails. In a palliative setting the endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) could represent an easy and valid option. We performed a prospective study with a new EC-LAMS with the primary aim to assess the clinical success rate of EUS-GBD as a first-line approach to the palliation of DMBO. In all, 37 consecutive patients undergoing EUS-GBD with a new EC-LAMS were prospectively enrolled. Clinical success was defined as bilirubin level decrease >15% within 24 h and >50% within 14 days after EC-LAMS placement. The mean age was 73.5 ± 10.8 years; there were 17 male patients (45.9%). EC-LAMS placement was technically feasible in all patients (100%) and the clinical success rate was 100%. Four patients (10.8%) experienced adverse events, one bleeding, one food impaction, and two cystic duct obstructions because of disease progression. No stent-related deaths were observed. The mean hospitalization was 7.7 ± 3.4 days. Median overall survival was 4 months (95% confidence interval 1-8). Endoscopic ultrasound-guided gallbladder drainage with the new EC-LAMS is a valid option in palliative endoscopic biliary drainage as a first-step approach in low survival patients with malignant jaundice unfit for surgery. A smaller diameter EC-LAMS should be preferred, particularly if the drainage is performed through the stomach, to avoid potential food impaction, which could result in stent dysfunction.

Response

My colleagues and I thank Professor Chiang1Chiang H.-C. The risk of using antiplatelet and/or anticoagulant treatment for hemorrhagic adverse events during EUS-guided biliary drainage.Gastrointest Endosc. 2023; 97: 1170Abstract Full Text Full Text PDF Google Scholar for his constructive comments regarding our article “Antiplatelet and/or anticoagulant treatment dose not increase hemorrhagic adverse events during EUS-guided biliary drainage,”2Ogura T. Nishioka N. Ueno S. et al.Antiplatelet and/or anticoagulant treatment does not increase hemorrhagic adverse events during EUS-guided biliary drainage.Gastrointest Endosc. 2020; 92: 659-666Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar and we welcome the opportunity to respond. As Professor Chiang mentioned, the sample size was small because bleeding itself was not frequently observed; however, the number of patients who underwent EUS-BD was relatively large. This fact may reflect that bleeding events themselves may be rare. We mentioned this limitation in the text, and we also stated that our results should be evaluated in a large patient cohort. According to Chiang’s analysis, resuming anticoagulant/antiplatelet (AC/AP) may be a risk factor for bleeding.1Chiang H.-C. The risk of using antiplatelet and/or anticoagulant treatment for hemorrhagic adverse events during EUS-guided biliary drainage.Gastrointest Endosc. 2023; 97: 1170Abstract Full Text Full Text PDF Google Scholar However, as we mentioned in the text, the patients’ backgrounds were various; also, other data associated with bleeding were not presented because of the retrospective nature of the study. However, in our study, visible bleeding was observed in only 1 patient who did not receive AC/AP treatment. In clinical practice, a fall in hemoglobin does not matter so much. In addition, a covered self-expandable metal stent was deployed during EUS-BD; therefore, a compression effect was obtained if bleeding occurred as an adverse event. Moreover, according to another recent study,3Okuno N. Hara K. Mizuno N. et al.Outcomes of endoscopic ultrasound-guided biliary drainage in patients undergoing antithrombotic therapy.Clin Endosc. 2021; 54: 596-602Crossref PubMed Scopus (4) Google Scholar EUS-BD can be performed in patients who have undergone AC/AP treatment. Although further study is needed, as Chiang1Chiang H.-C. The risk of using antiplatelet and/or anticoagulant treatment for hemorrhagic adverse events during EUS-guided biliary drainage.Gastrointest Endosc. 2023; 97: 1170Abstract Full Text Full Text PDF Google Scholar points out, we think that EUS-BD can be performed safely. Once again, we would like to thank Professor Chiang for these valuable comments. The author disclosed no financial relationships.

P-83 Preoperative endoscopic biliary drainage procedures may affect intrahepatic recurrence of cholangiocarcinoma after surgical resection

P-83 Preoperative endoscopic biliary drainage procedures may affect intrahepatic recurrence of cholangiocarcinoma after surgical resection

Outcomes and predictors of delayed endoscopic biliary drainage for severe acute cholangitis due to choledocholithiasis in an intensive care unit.

Acute cholangitis (AC) is an infection of the biliary tract secondary to biliary obstruction requiring biliary drainage through endoscopic retrograde cholangiopancreatography. This study aims to compare the outcome between the early and delayed ERCP in patients with severe AC. Patient with severe AC due to choledocholithiasis admitted to intensive care unit were included. Early ERCP was defined was as ERCP performed within 24h following hospital admission. Propensity-score matching was used to reduce the imbalance between groups. The primary outcome was 30-day mortality. Secondary outcomes included length of hospital and ICU stay, onset or persistent organ failure. The delayed ERCP group had a higher mortality rate at 30 days (45,5 versus 13%, <0.001) and at 1 year (59,7% versus 15,6%, p <0.001). Delayed ERCP had also a higher rate of respiratory adverse events (54,5 versus 27,8%, p=0,002), longer ICU (7.41 versus 4.61, p=0,004) and hospital (11,88 versus 9,22, p=0,042) length of stay. Predictors of delayed ERCP were cardiac arrythmias, liver disease, creatinine value and white blood cell count at baseline. Delays in ERCP for patients with severe AC appear to be associated with higher mortality rate and prolonged ICU and hospital stays.

The Role of Lumen Apposing Metal Stents in the Palliation of Distal Malignant Biliary Distal Obstruction.

Malignant biliary obstruction (DMBO) has been traditionally managed by endoscopic retrograde cholangiopancreatography (ERCP). In the case of ERC failure, percutaneous transhepatic biliary drainage (PT-BD) has been widely utilized as a salvage procedure. However, over the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has gained increasing popularity, especially after the advent of electrocautery-enhanced lumen apposing metal stent devices (EC-LAMSs) which enable a one-step procedure, granting prevention of biliary leakage and minimizing occurrence of adverse events (AEs). In parallel, increasing evidence suggests a possible role of EUS-BD in the management of DMBO as a primary palliative drainage modality. In the current paper, we aim to review all the available evidence on the role of EUS-BD performed with EC-LAMSs and discuss salient technical aspects of this type of procedure.

A Systematic Review of Endoscopic Treatments for Concomitant Malignant Biliary Obstruction and Malignant Gastric Outlet Obstruction and the Outstanding Role of Endoscopic Ultrasound-Guided Therapies.

The treatments for cancer palliation in patients with concomitant malignant biliary obstruction (MBO) and gastric outlet obstruction (MGOO) are still under investigation due to the lack of evidence available in the medical literature. We performed a systematic search and critical review to investigate efficacy and safety among patients with MBO and MGOO undergoing both endoscopic ultrasound-guided biliary drainage (EUS-BD) and MGOO endoscopic treatment. A systematic literature search was performed in PubMed, MEDLINE, EMBASE, and the Cochrane Library. EUS-BD included both transduodenal and transgastric techniques. Treatment of MGOO included duodenal stenting or EUS-GEA (gastroenteroanastomosis). Outcomes of interest were technical success, clinical success, and rate of adverse events (AEs) in patients undergoing double treatment in the same session or within one week. 11 studies were included in the systematic review for a total number of 337 patients, 150 of whom had concurrent MBO and MGOO treatment, fulfilling the time criteria. MGOO was treated by duodenal stenting (self-expandable metal stents) in 10 studies, and in one study by EUS-GEA. EUS-BD had a mean technical success of 96.4% (CI 95%, 92.18-98.99) and a mean clinical success of 84.96% (CI 95%, 67.99-96.26). The average frequency of AEs for EUS-BD was 28.73% (CI 95%, 9.12-48.33). Clinical success for duodenal stenting was 90% vs. 100% for EUS-GEA. EUS-BD could become the preferred drainage in the case of double endoscopic treatment of concomitant MBO and MGOO in the near future, with the promising EUS-GEA becoming a valid option for MGOO treatment in these patients.

Acute Cholangitis with Common Bile Duct Stone Caused by &lt;i&gt;Lactococcus garvieae&lt;/i&gt;: A Case Report

&lt;i&gt;Lactococcus garvieae&lt;/i&gt; is a Gram-positive cocci that has been known to be a fish pathogen, and considered as a low virulence organism rarely associated with human infection. We report a case of acute cholangitis with common bile duct (CBD) stone and bacteremia by &lt;i&gt;L. garvieae&lt;/i&gt; bacteremia in a 70-year-old male. The patient presented with epigastric pain and was diagnosed with two CBD stones. Blood culture obtained prior to empiric antimicrobial therapy with ceftizoxime sodium showed growth with &lt;i&gt;Escherichia coli&lt;/i&gt; and &lt;i&gt;L. garvieae&lt;/i&gt;. The bacteria were confirmed by matrix-assisted desorption/ionization time-of-flight mass spectrometry. Initial attempt at endoscopic biliary drainage failed, and the patient underwent percutaneous transhepatic biliary drainage and subsequent stone removal. He occasionally ingested raw fish and had a history of gastric ulcer with acid suppression therapy, which could be possible risk factors for &lt;i&gt;L. garvieae&lt;/i&gt; infection. This is the first case of &lt;i&gt;L. garvieae&lt;/i&gt; bacteremia in acute cholangitis.

Multimodal Management for Refractory Biliary Stricture After Living Donor Liver Transplantation

Biliary stricture is a common complication of living donor liver transplantation (LDLT). Endoscopic retrograde biliary drainage (ERBD) is the primary treatment of biliary stricture, which is sometimes refractory. This study aimed to evaluate the risk factors for biliary stricture after LDLT and present successful management for refractory biliary stricture. Data from 26 patients who underwent LDLT were retrospectively analyzed. The relationship between the incidence of biliary strictures and clinical variables, including pre/intra/postoperative factors, was assessed. Univariate analysis showed that ABO incompatibility (P=.037) was a significant risk factor for biliary strictures. Case 1 was a 57-year-old woman who underwent LDLT using a left-lobe graft for primary biliary cholangitis (PBC) and developed a biliary stricture 1 month after surgery. Percutaneous transhepatic cholangiodrainage (PTCD) and embolization of the portal vein and hepatic artery were performed. Thereafter, ethanol was injected into the biliary duct, and the intervention was successfully completed. Case 2 was a 54-year-old woman who underwent LDLT using a right-lobe graft and duct-to-duct biliary reconstruction for PBC. Internal plastic stent insertion by ERBD was unsuccessful due to the significantly bending bile duct. After PTCD, the gun-site technique for the posterior branch and dual hepatic vascular embolization of the anterior branch was performed. The patient was followed up without an external fistula tube. ABO incompatibility was a risk factor for refractory biliary stricture. Appropriate procedures should be chosen based on stricture types.

Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part II (Technical Aspects)

AbstractEndoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined, and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreatography (ERCP). However, even in expert hands, the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or, more commonly, percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreaticobiliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD, and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, however, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories, making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, Society of Gastrointestinal Endoscopy of India (SGEI) deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Tips and tricks for endoscopic ultrasound-guided hepaticogastrostomy.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a treatment option for patients with biliary obstruction in whom traditional endoscopic retrograde cholangiopancreatography (ERCP) is not possible due to altered upper gastrointestinal anatomy. In such cases, EUS-BD is a good alternative to surgery or percutaneous transhepatic biliary drainage (PTBD), with comparable clinical and technical success rates [1]. Two approaches have been described for EUS-guided transluminal biliary drainage. EUS-guided hepaticogastrostomy uses the transgastric approach and EUS-guided choledochoduodenostomy uses the transduodenal approach [2].

Diagnosis and Treatment of Perihilar Cholangiocarcinoma: A National Survey from the Korean Pancreatobiliary Association.

Based on their anatomy, cholangiocarcinomas (CCAs) are classified into intrahepatic, hilar, and distal CCAs. Although the diagnosis and treatment of each type of CCA are thought to be different, real-world data studies on the current practice are limited. Therefore, this study was designed to capture the current practice of diagnosing and treating perihilar CCA in Korea. We conducted a survey using an online platform. The questionnaire consisted of 18 questions designed to evaluate the current practice of diagnosing and treating perihilar CCA in Korea. The targets of this survey were biliary endoscopists who are members of the Korean Pancreatobiliary Association. In total, 119 biliary endoscopists completed the survey. Of the respondents, 89.9% thought that the use of the International Classification of Diseases, 11th Revision (ICD-11) system is necessary to classify CCA. Approximately half of the respondents would recommend surgery or chemotherapy until patients were 80 years of age. For the pathological diagnosis of CCA, endoscopic retrograde cholangiopancreatography with biopsy was the most preferred modality. Routine preoperative biliary drainage was performed by 44.5% of the respondents. For operable CCAs, 64.7% of the respondents preferred endoscopic biliary drainage using plastic stents. For palliative biliary drainage, 69.7% of the respondents used plastic stents. For palliative endoscopic biliary drainage using metal stents, 63% of the respondents preferred the stent-in-stent method. A new coding system using the ICD-11 is needed for classifying CCAs. Guidelines for diagnosing and treating CCA based on the clinical situation in Korea are needed.

The efficacy of a novel integrated outside biliary stent and nasobiliary drainage catheter system for acute cholangitis: a single center pilot study.

Endoscopic biliary drainage is the gold standard treatment for cholangitis. The two methods of biliary drainage are endoscopic biliary stenting and nasobiliary drainage. A novel integrated outside biliary stent and nasobiliary drainage catheter system (UMIDAS NB stent; Olympus Medical Systems) was recently developed. In this study, we evaluated the efficacy of this stent in the treatment of cholangitis caused by common bile duct stones or distal bile duct strictures. We conducted a retrospective pilot study by examining the medical records of patients who required endoscopic biliary drainage for cholangitis due to common bile duct stones or distal bile duct strictures, and who were treated with a UMIDAS NB stent, between December 2021 and July 2022. Records of 54 consecutive patients were reviewed. Technical and clinical success rates were 47/54 (87.0%) and 52/54 (96.3%), respectively. Adverse events were observed in 12 patients, with six patients experiencing pancreatitis as an adverse event, following endoscopic retrograde cholangiopancreatography (ERCP). Regarding late adverse events, five cases of biliary stent migration into the bile duct were observed. Disease-related death occurred in one patient. The outside-type UMIDAS NB stent is an efficacious new method for biliary drainage and can be applied to many indications.