Endosonography-guided Biliary Drainage Research Articles

Quality of Life and Clinical Outcomes of Endosonography-Guided Biliary Drainage in Patients with Malignant Biliary Obstruction: A Single-Center, Prospective Analysis.

Introduction: Endosonography-guided biliary drainage (EUS-BD) serves as a rescue treatment modality for patients with malignant biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) fails. Objectives: This study explores the effects of EUS-BD on liver function and quality of life (QoL). Patients and Methods: Patients with malignant biliary obstruction and failed ERCP were enrolled to undergo EUS-BD. QoL, including pruritus severity, was evaluated using EQ-5D-5L and PSS-10 questionnaires before and after EUS-BD. Serum bilirubin and liver function tests were measured on the procedure day, two days, and at least 14 days post-procedure. Results: During a 20-month study period, 1755 ERCPs were performed, with 595 for malignant cases. Of these, 49 underwent EUS-BD following failed ERCP, and 37 (54% women, age range 34-87 years) completed the 14-day follow-up. Pancreatic cancer was the most common (49%) condition, and the median hospital stay was 4 days. Serum bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transferase significantly decreased 2 and 14 days after EUS-BD (all p < 0.001). Pruritus significantly improved, with an average reduction of 5.19 points on the PSS-10 scale two weeks post-procedure (p < 0.001). EUS-BD led to improvements in anxiety and depression according to the EQ-5D-5L (p = 0.013). Conversely, deteriorations were observed in the Mobility, Self-Care, and Usual Activities domains over time (all p < 0.05). Successful EUS-BD enabled the resumption of chemotherapy in 11 (30%) patients. The median post-procedure survival was 112 (range 27-1030) days. Conclusions: EUS-BD improves liver parameters and some aspects of life quality in patients with malignant biliary obstruction, thereby increasing their eligibility for optimal palliative care.

Su1324 ENDOSCOPIC ULTRASOUND-GUIDED BILIARY DRAINAGE FOLLOWING FAILED ERCP: EXPERIENCE FROM A UNITED KINGDOM TERTIARY REFERRAL CENTRE 2016-2019

Percutaneous transhepatic biliary drainage (PTBD) is associated with significant morbidity and prolonged hospital stays [1,2]. Endosonography-guided biliary drainage (EUS-BD) is an alternative to PTBD when endoscopic retrograde pancreatography (ERCP) has failed. The aims of this study were to review the technical success and adverse events with EUS-BD procedures performed at a tertiary care referral centre. A prospectively-collected database of EUS-BD procedures performed at a single centre from 1st August 2016 to 20th November 2019 was reviewed retrospectively. Procedures were performed by two experienced operators. Recorded variables were technical success, adverse events, length of stay and 30-day all-cause mortality. A total of 82 procedures were performed. 45 patients were male (55%) and median age was 70 years (range 20-90 years). Indications for drainage were malignant obstruction secondary due to pancreaticobiliary malignancy (n =55), choledocholithiasis (n=14), other metastatic malignancies (n=7), chronic pancreatitis (n=5) and benign duodenal stricture (n=1). Reasons for failed ERCP were inaccessible papilla due to gastric outlet obstruction (n=29), tumour infiltration of ampulla (n=26), obscured intradiverticular ampulla (n=16) and failure to transverse biliary stricture (n=11). The route of attempted biliary drainage was choledochoduodenostomy in 56, EUS-guided rendezvous in 14 and hepaticogastrostomy in 12. The procedures were technically successful in 95.1%. The adverse event rate was 7.3%. Failures and adverse events are detailed in the table. The median length of stay was 3 days (range 0-120) days. Two patients died within 30 days, both of multiorgan failure in the context of pre-existing sepsis which did not resolve following EUS-BD. This study adds to the existing literature supporting EUS-BD [3-5] as an effective and safe alternative to PTBD after failed ERCP. The rendezvous technique seems less successful than choledochoduodenostomy or hepaticogastrostomy in this series. Further prospective randomised studies are needed to compare outcomes for EUS-guided versus percutaneous drainage.

Forward-viewing echoendoscope is useful for recanalization of postoperative biliary anastomotic atresia in endosonography-guided biliary drainage.

Forward-viewing echoendoscope is useful for recanalization of postoperative biliary anastomotic atresia in endosonography-guided biliary drainage.

Different options of endosonography-guided biliary drainage after endoscopic retrograde cholangio-pancreatography failure.

AIMTo investigate the success rates of endosonography (EUS)-guided biliary drainage (EUS-BD) techniques after endoscopic retrograde cholangiopancreatography (ERCP) failure for management of biliary obstruction.METHODSFrom Feb/2010 to Dec/2016, ERCP was performed in 3538 patients, 24 of whom (0.68%) suffered failure to cannulate the biliary tree. All of these patients were initially submitted to EUS-guided rendez-vous (EUS-RV) by means of a transhepatic approach. In case of failure, the next approach was an EUS-guided anterograde stent insertion (EUS-ASI) or an EUS-guided hepaticogastrostomy (EUS-HG). If a transhepatic approach was not possible or a guidewire could not be passed through the papilla, EUS-guided choledochoduodenostomy (EUS-CD) was performed.RESULTSPatients were submitted to EUS-RV (7), EUS-ASI (5), EUS-HG (6), and EUS-CD (6). Success rates did not differ among the various EUS-BD techniques. Overall, technical and clinical success rates were 83.3% and 75%, respectively. Technical success for each technique was, 71.4%, 100%, 83.3%, and 83.3%, respectively (P = 0.81). Complications occurred in 3 (12.5%) patients. All of these cases were managed conservatively, but one patient died after rescue percutaneous transhepatic biliary drainage (PTBD).CONCLUSIONThe choice of a particular EUS-BD technique should be based on patient’s anatomy and on whether the guidewire could be passed through the duodenal papilla.

Palliation: Hilar cholangiocarcinoma.

Hilar cholangiocarcinomas are common tumors of the bile duct that are often unresectable at presentation. Palliation, therefore, remains the goal in the majority of these patients. Palliative treatment is particularly indicated in the presence of cholangitis and pruritus but is often also offered for high-grade jaundice and abdominal pain. Endoscopic drainage by placing stents at endoscopic retrograde cholangio-pancreatography (ERCP) is usually the preferred modality of palliation. However, for advanced disease, percutaneous stenting has been shown to be superior to endoscopic stenting. Endosonography-guided biliary drainage is emerging as an alternative technique, particularly when ERCP is not possible or fails. Metal stents are usually preferred over plastic stents, both for ERCP and for percutaneous biliary drainage. There is no consensus as to whether it is necessary to place multiple stents within advanced hilar blocks or whether unilateral stenting would suffice. However, recent data have suggested that, contrary to previous belief, it is useful to drain more than 50% of the liver volume for favorable long-term results. In the presence of cholangitis, it is beneficial to drain all of the obstructed biliary segments. Surgical bypass plays a limited role in palliation and is offered primarily as a segment III bypass if, during a laparotomy for resection, the tumor is found to be unresectable. Photodynamic therapy and, more recently, radiofrequency ablation have been used as adjuvant therapies to improve the results of biliary stenting. The exact technique to be used for palliation is guided by the extent of the biliary involvement (Bismuth class) and the availability of local expertise.

超音波内視鏡下胆道ドレナージ（ESBD）の有用性

超音波内視鏡下胆道ドレナージ（ESBD）の有用性

Comparison of endosonography-guided vs. percutaneous biliary stenting when papilla is inaccessible for ERCP.

Endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting fails in 5-10% patients of malignant biliary obstruction because papilla is inaccessible. Percutaneous transhepatic biliary drainage (PTBD) is an accepted alternative. Endosonography-guided biliary drainage (EUS-BD) has been described recently. To compare success rates and complications of EUS-BD and PTBD internal stenting. This retrospective study included failed ERCP in inoperable malignant biliary obstruction due to inaccessible papilla undergoing PTBD or EUS-BD. Percutaneous transhepatic cholangiography guided/EUS-guided rendezvous procedures were excluded. When PTBD internal stenting failed, external drainage was performed. EUS-BD was performed using either intra- or extrahepatic approach, and stents were placed by transmural (choledocho-duodenostomy or hepatico-gastrostomy) or antegrade approach. Self-expandable metallic stents or plastic stents were placed in both groups. Success of internal stenting and complications were compared using t-test and chi-squared test. Retrospective review of 6 years of records (2005-2011) revealed 50 patients meeting the required criteria. EUS-BD was attempted in 25 and PTBD in 26 patients (one crossover from EUS-BD to PTBD). Internal stenting was technically and clinically successful in 23/25 (92%) EUS-BD vs. 12/26 (46%) PTBD (p < 0.05). External catheter drainage was performed in remaining 14 PTBD patients. Complications occurred in 5/25 (20%) EUS-BD (one major, four minor) and in 12/26 (46%) PTBD (four major, eight minor; p < 0.05). Late stent occlusion occurred in one EUS-BD and three PTBD. In this retrospective study comparing success and complications of EUS-BD and PTBD in patients with inoperable malignant biliary obstruction and inaccessible papilla, EUS-BD was found superior to PTBD for both comparators.

Metallic stent deployment in endosonography‐guided biliary drainage: Long‐term follow‐up results in patients with bilio‐enteric anastomosis

Although reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few reports on deployment of a self-expandable metal stents (SEMS) have been reported. The aim of the present study was to evaluate the safety and efficacy of SEMS deployment in ESBD. Of 42 patients who underwent ESBD during the period from January 2007 to August 2011, 21 patients with unresectable malignant biliary obstruction in whom SEMS deployment had been attempted were included. In the first session, a plastic stent or SEMS was placed in a bilio-enteric anastomosis (BEA) method. SEMS was deployed with the one-step technique or with replacement of a plastic stent with a SEMS in the second session. The technical success, early and late complications, and stent patency of SEMS were evaluated. One-step SEMS deployment was attempted in seven patients, and SEMS was deployed with stent exchange in 14. SEMS deployment was successful in all patients without any complications. Finally, SEMS was placed in a BEA method in 16 patients (extrahepatic bile duct, 13; intrahepatic bile duct, three), and with antegrade deployment in five. Late complications occurred in three patients who underwent deployment of SEMS in a BEA method (stent obstruction in two and reflux cholangitis in one). The mean stent patency period was 433 days. As SEMS deployment in ESBD is safe and provides long stent patency, a SEMS seems to be the stent of choice in ESBD for patients with unresectable malignant biliary obstruction in whom long survival is expected.

Tu1548 Metallic Stent Deployment in Endosonography-Guided Biliary Drainage: Long Term Follow-up Results in Patients With Bilio-Enteric Anastomosis

Though reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few case series have been reported on deployment of a self-expandable metal stent (SEMS) and its long-term results. Aim: To evaluate the safety and efficacy of SEMS deployment in ESBD.

Indications and current problems for endosonography-guided biliary drainage (ESBD)

Indications and current problems for endosonography-guided biliary drainage (ESBD)

Su1438 Efficacy and Safety of a Newly Developed Fully Covered Biliary Metallic Stent in Comparison With the Partially Covered WallFlex Biliary RX Stent for Unresectable Malignant Biliary Stricture

Su1438 Efficacy and Safety of a Newly Developed Fully Covered Biliary Metallic Stent in Comparison With the Partially Covered WallFlex Biliary RX Stent for Unresectable Malignant Biliary Stricture Takahisa Ogawa, Kei Ito, Naotaka Fujita, Yutaka Noda, Go Kobayashi, Takashi Obana, Jun Horaguchi, Shinsuke Koshita, Yoshihide Kanno Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan Background and aim: Endoscopic self-expandable metallic stent (SEMS) placement is widely accepted as a palliative therapy in patients with unresectable malignant biliary stricture. Although a covered SEMS has been reported to have a longer stent patency than an uncovered SEMS, complications such as stent migration and kinking of the bile duct can occur after deployment. A newly developed fully covered biliary metallic stent (ZEOSTENT Covered (ZEO), Zeon Medical Inc., Tokyo, Japan) which has an uneven outer surface, a low shortening ratio, and a low axial force might reduce such complications. The aim of this study was to evaluate the efficacy and safety of this new covered biliary stent in comparison with the partially covered WallFlex Biliary RX Stent (Wall) (Boston Scientific, Co., Ltd., Natic, MA, USA). Patients and methods: Between March 2010 and November 2010, endoscopic placement of a ZEO was performed in 24 patients (mean age, 77 10 yrs; 10 males, 14 females) with unresectable malignant biliary stricture. Fifteen patients had pancreatic cancer, 4 had bile duct cancer, 2 had gallbladder cancer, 2 had ampullary cancer and 1 had lymph node metastases from other cancers. Main outcome measurements were success rate of the procedure, early complications, late complications, and stent patency. Early complications were defined as those which occurred within 3 days after stent placement. Such data were compared with those of 24 patients (mean age, 75 12 yrs; 13 males, 11 females) who had undergone endoscopic placement of a Wall between April 2009 and July 2010. Results: Mean follow-up duration of the ZEO group and the Wall group were 77 days and 124 days, respectively (P 0.024). Stent placement was successful and improvement of jaundice was obtained in all patients of both groups. ZEO and Wall were transpapillarily placed in 18 and 22 patients, respectively. Transduodenal and transgastric stent placement utilizing the endosonography-guided biliary drainage route was performed in 5 and 2 patients, respectively. Early complications occurred in 1 patient in the ZEO group (pancreatitis, 1) and in 4 in the Wall group (pancreatitis, 3; cholecystitis,1) (P 0.17). Late complications occurred in 5 patients of the ZEO group (stent occlusion, 4; stent migration, 1; cholecystitis, 1) and in 6 of the Wall group (stent occlusion, 1; stent migration, 2; cholecystitis, 3; cholangitis without stent occlusion, 1) (P 1.00). In 3 cases of the ZEO group, tumor ingrowth occurred due to breakage of the cover, whereas there were no such cases in the Wall group. Mean stent patency duration of the ZEO group and the Wall group were 243 days and 382 days, respectively (P 0.20). Conclusion: The short-term efficacy and safety of ZEO were comparable with those of Wall. However, improvement of the cover of the ZEO is indispensable for prevention of tumor ingrowth.

Sa1470 Does Endosonography-Guided Biliary Drainage Replace Percutaneous Transhepatic Biliary Drainage for Malignant Biliary Obstruction After Failed ERCP?

Although endoscopic ultrasound-guided biliary drainage (EUS-BD) may be a useful alternative method of biliary drainage in patients with failed endoscopic transpapillary biliary drainage, there are limited data on the outcomes and complications of EUS-BD. We compared the efficacy and the safety of EUS-BD to percutaneous transhepatic biliary drainage (PTBD) after failed ERCP in patients with malignant biliary obstruction.

One-step Placement of a Fully-covered Metal Stent in Endosonography-guided Biliary Drainage for Malignant Biliary Obstruction

Although reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few discuss deployment of a self-expandable metal stent (SEMS) in the first session. To evaluate the safety and efficacy of ESBD with the one-step placement of a newly designed fully-covered SEMS. Five patients with malignant biliary obstruction in whom one-step placement of an anti-migration designed SEMS in the first session of ESBD had been attempted between January 2007 and October 2009 were included in this study. Main outcome measurements were technical and clinical successes, early complications, and short-term results. ESBD was attempted to bridge the extrahepatic bile duct and the duodenum and one-step SEMS placement was successful in all cases. There were no early complications related to ESBD and excellent biliary decompression was obtained in all cases. SEMS dysfunction such as stent migration and occlusion was not seen during the follow-up period (mean follow-up 138 days, range 102-184 days). One-step placement of a fully-covered SEMS in ESBD is possibly a safe and effective treatment for biliary obstruction.

Endosonography-Guided Biliary Drainage with One-Step Placement of a Newly Developed Fully Covered Metal Stent Followed by Duodenal Stenting for Pancreatic Head Cancer

An 83-year-old man was admitted to our department, presenting with jaundice, fever, and nausea. CT revealed a pancreatic head tumor with duodenal invasion. Endoscopic transpapillary biliary drainage was unsuccessful due to stenosis at the second portion of the duodenum and tumor invasion to the papilla of Vater. Using a convex linear array echoendoscope, a fully-covered metal stent was placed across the puncture tract to bridge the duodenum and the bile duct. After improvement of jaundice, a duodenal metal stent was placed across the stricture of the duodenum. No procedure-related complications occurred. Neither migration nor obstruction of the two stents was observed during the three months followup period. Combination of ESBD using a fully covered metal stent and duodenal stenting is a feasible technique and possibly a less invasive treatment option for malignant biliary and duodenal obstruction compared to surgery.

TRANSGASTRIC TRANSHEPATIC ENDOSONOGRAPHY-GUIDED BILIARY DRAINAGE: HISTOLOGICAL ASSESSMENT OF ITS SINUS TRACT IN AN AUTOPSY CASE

Endosonography-guided biliary drainage (ESBD) is gaining attention as a promising drainage technique for obstructive jaundice. However, histological changes resulting from ESBD have not been well understood. We had an opportunity to histologically investigate the influence of ESBD, established between the left hepatic duct and the stomach, on the relevant organs in an autopsy case with bile duct cancer extending from the pancreatic head to the hepatic hilum with duodenal invasion. Localized fibrous connective tissues were present around and along the sinus tract, including the connection between the surfaces of the left lobe of the liver and the gastric serosa, without hemorrhage, inflammatory changes, or cancer invasion. The inside of the ESBD stent was slightly stenotic at the intramural portion of the stomach due to proliferation of granulation tissue. No bile stasis or abscess was observed in the left lobe. These results are quite suggestive of the high safety and efficacy of ESBD with adequate performance.

CURRENT ISSUES REGARDING ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE FOR BILIARY OBSTRUCTION

Transpapillary endoscopic biliary drainage is a well-accepted technique for patients with biliary obstruction. However, transpapillary access to the bile duct is not always possible, especially in patients with duodenal stenosis or difficult cannulation of the bile duct during endoscopic retrograde cholangiopancreatography. Percutaneous transhepatic biliary drainage or surgical bypass has been performed in cases of unsuccessful endoscopic retrograde cholangiopancreatography. Recently, endosonography-guided biliary drainage (ESBD) has been developed as a new biliary drainage technique. Current issues regarding ESBD are discussed in this article. Proper indications for ESBD should be established for widespread performance. Technical standardization and dedicated instruments for ESBD are also mandatory.

ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE IN CASES WITH DIFFICULT TRANSPAPILLARY ENDOSCOPIC BILIARY DRAINAGE

Recently, reports on a new endoscopic biliary drainage technique utilizing endosonographic guidance (endosonography-guided biliary drainage [ESBD]) have been increasing. The aim of this study was to evaluate the efficacy of ESBD in cases with difficult transpapillary endoscopic biliary drainage (EBD). Sixteen patients with obstructive jaundice who underwent ESBD because of difficult EBD between January 2007 and September 2008 were included. The technical success, complications, and clinical efficacy of ESBD were prospectively evaluated. ESBD was performed via the duodenum, stomach, and esophagus in eight, six and two patients, respectively. Stent placement was successful in all cases and excellent biliary decompression was achieved in all but one patient. One patient developed localized peritonitis following guidewire migration and re-puncture of the bile duct. In another patient, stent migration was observed one week after ESBD and re-ESBD was carried out. Three patients underwent surgery for their primary diseases, and stent exchange was carried out in 10 patients during the course. ESBD is an effective treatment for obstructive jaundice that will replace percutaneous transhepatic biliary drainage in cases of difficult EBD and is a possible alternative to EBD in selected cases.

A Case of Unresectable Pancreatic Carcinoma Treated by Chemotherapy, Endosonography-Guided Biliary Drainage, and Endoscopic Duodenal Stent Placement

患者は78歳の男性.黄疸を主訴に当科へ紹介となった.腹部超音波検査では，膵頭部に辺縁不整な低エコー腫瘤が指摘された.肝外，肝内胆管拡張，および肝内に多数の低エコー腫瘤を認めた.胆道ドレナージを目的にERCPを試みたが，癌浸潤に伴う十二指腸狭窄にて不成功で，胃内から肝外胆管を標的胆管として，超音波内視鏡ガイド下胆道ドレナージ（ESBD：Endosonography-guided biliary drainage）を施行した.肝転移により手術適応無く，減黄後gemcitabine化学療法を導入した.その後，十二指腸狭窄が増悪し食事摂取が困難となったために，内視鏡下に十二指腸ステント留置を行った.内視鏡治療により良好なQOLが得られたが，初診から約6ヶ月後に原病死となった.化学療法の進歩した現在，全身状態の改善をめざした悪性胆道·消化管狭窄に対する内視鏡的interventionは，積極的に試みるべきと考えられた.

SNARE‐OVER‐THE‐WIRE TECHNIQUE FOR SAFE EXCHANGE OF A STENT FOLLOWING ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE

Endosonography-guided biliary drainage (ESBD) is a new option that allows establishment of biliary drainage. Due to the diameter of the working channel of an echoendoscope, it is necessary to replace a small caliber stent with a larger one to lessen the risk of stent occlusion. However, insertion of a guidewire into the bile duct via the hole of the sinus tract following direct removal of a previously placed stent is not always possible, resulting in guidewire passage outside the fistula and bile leakage. Cannulation of the previously deployed stent, guidewire insertion into the bile duct via the cannula and the stent, and removal of the stent with the snare over the guidewire leaving the guidewire in place (the snare-over-the-wire technique [SOW]) for stent exchange following ESBD was attempted. Four patients who required stent exchange following ESBD were included in the present study to evaluate the feasibility and usefulness of SOW. SOW was successful in all the cases. A new stent was also successfully deployed over the guidewire in all the cases. No complications were encountered. The snare-over-the-wire technique is feasible and useful in stent exchange following ESBD for the reduction of the risk of guidewire migration.

ENDOSONOGRAPHY‐GUIDED GALLBLADDER DRAINAGE FOR ACUTE CHOLECYSTITIS FOLLOWING COVERED METAL STENT DEPLOYMENT

Endosonography-guided biliary drainage (ESBD) is gaining acceptance as an effective treatment for obstructive jaundice. Only a few reports on the application of this technique to the gallbladder (endosonography-guided gallbladder drainage [ESGBD]) have been published in the literature. In order to relieve acute cholecystitis which developed in a patient with unresectable malignant biliary obstruction after deployment of a covered metal stent (CMS), we applied this technique. ESGBD was carried out by using an electronic curved linear array echoendoscope. After visualization of the gallbladder and determination of the puncture route, a needle knife papillotome was advanced with electrocautery to pierce the gastric and gallbladder walls. Under the guidance of a guidewire inserted through the needle sheath into the gallbladder, a 7.2 Fr, 30 cm-long, single pigtail plastic tube was placed to bridge the gallbladder and the stomach. No complications relevant to the procedure were encountered. ESGBD was quite effective in ameliorating the patient's acute cholecystitis and the drainage tube was removed after 10 days without sequelae. Acute cholecystitis following CMS deployment is considered to be a good indication for ESGBD.