Inaccessible Papilla Research Articles

Multicenter study comparing EUS-guided hepaticogastrostomy and ERCP for malignant biliary obstruction in patients with accessible papillae.

One advantage of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is that it is difficult for reflux cholangitis, caused by duodenal pressure increasing due to duodenal obstruction, to occur. In addition, since stent deployment is performed away from the malignant stricture site, longer stent patency than with endoscopic retrograde cholangiopancreatography (ERCP) may be obtained. However, no study has previously compared EUS-HGS and ERCP for patients without duodenal obstruction or surgically altered anatomy. The aim of the present study was to compare clinical outcomes between EUS-HGS and ERCP in normal anatomy patients without duodenal obstruction. In the ERCP group, patients who initially underwent biliary drainage were included. In the EUS-HGS group, patients who underwent EUS-HGS due to failed biliary cannulation were included. Patients with an inaccessible papilla, such as with surgically altered anatomy or duodenal obstruction, were excluded. A total of 314 patients who underwent ERCP and EUS-HGS were enrolled in this study. Of the 314 patients, 289 underwent biliary stenting under ERCP guidance, and 25 patients underwent biliary stenting under EUS-HGS. After propensity score-matching analysis, the adverse event rate tended to be lower in the EUS-HGS group than in the ERCP group. Although overall survival was not significantly different between the EUS-HGS and ERCP groups (p = .228), stent patency was significantly longer in the EUS-HGS group (median 366.0 days) than in the ERCP group (median 76.5 days). EUS-HGS had a lower adverse event rate, shorter procedure time, and longer stent patency than ERCP in cases of normal anatomy without duodenal obstruction.

EUS-BD for calibration of benign stenosis of the bile duct in patients with altered anatomy or inaccessible papilla.

Background and study aims In cases of inaccessible papilla, EUS-guided biliary drainage (EUS-BD) has been described as an alternative to calibrate benign biliary stenosis. However, few studies are available. Patients and methods This tw-center, retrospective study was designed to evaluate technical success and clinical success at 1 year. All patients who underswent EUS-BD without the rendezvous technique used for calibration of benign biliary stenosis were included from 2016 to 2022. Patients underwent EUS-hepaticogastrostomy (EUS-HGS) during the first session. Then, HGS was used to access the bile duct, allowing calibration of the stenosis: Dilation of the biliary stenosis and placement of double pigtail stents through the stenosis for 1 year. Results Thirty-six patients were included. Technical success was 89% (32/36), with four failures to cross the stenosis but EUS-HGS was performed in 100% of the cases. Nine patients were excluded during calibration because of oncological relapse in six and complex stenosis in three. Three patients had not yet reached 1 year of follow-up. Twenty patients had a calibration for at least 1 year. Clinical success after stent placement was considered in all cases after 1 year of follow-up. Thirteen patients underwent stent removal and no relapse occurred after 435 days of follow-up (SD=568). Global morbidity was 41.7% (15/36) with only one serious complication (needing intensive care), including seven cases of cholangitis due to intrabiliary duct obstruction and five stent migrations. No deaths were reported. Conclusions EUS-BD for calibration in case of benign biliary stenosis is an option. Dedicated materials are needed to decrease morbidity.

Endoscopic ultrasound-guided intervention for inaccessible papilla in advanced malignant hilar biliary obstruction.

Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may be warranted. Transpapillary drainage may not be feasible in patients with surgically altered anatomy, duodenal stenosis, prior duodenal self-expanding metal stent, and after initial transpapillary drainage, but require re-intervention for draining separated liver segments. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous trans-hepatic biliary drainage are the feasible options in this scenario. The major advantages of EUS-BD over percutaneous trans-hepatic biliary drainage include a reduction in patient discomfort and internal drainage away from the tumor, thus reducing the possibility of tissue or tumor ingrowth. With innovations, EUS-BD is helpful not only for bilateral communicating MHBO but also for non-communicating systems with bridging hilar stents or isolated right intra-hepatic duct drainage by hepatico-duodenostomy. EUS-guided multi-stent drainage with specially designed cannulas and guidewires has become a reality. A combined approach with endoscopic retrograde cholangiopancreatography for re-intervention, interventional radiology, and intraductal tumor ablative therapies has been reported. Stent migration and bile leakage can be minimized with proper stent selection and technique, and stent blocks can be managed with EUS-guided interventions in a majority of cases. Future comparative studies are required to establish the role of EUS-guided interventions in MHBO as rescue or primary therapy.

HPB P37 Outcomes following EUS choledocho-duodenostomy for the palliative treatment of peri-ampullary cancer following unsuccessful ERCP – A single centre experience

Abstract Background EUS-guided choledocho-duodenostomy is an option to relieve jaundice after a failed ERCP, in patients with locally advanced or metastatic peri-ampullary cancers. We aim to assess the technical success, safety and outcomes of the procedure in our practice. Methods All consecutive adult patients that underwent EUS-guided CBD stent placement after a failed ERCP between December 2019 and May 2022 at the Queens Medical Centre, Nottingham were included. Studied variables included demographics, technical characteristics and outcomes including length of stay, normalisation of bilirubin level, complication rate and 30-day mortality rate. Results Twenty-six consecutive patients were included in this study (12 males, 14 females). The mean age was 75 (range 52–92) years. Pancreatic cancer was present in 15 patients (57.6%), 4 patients (15.3%) each had ampullary cancer and other malignant peri-ampullary lesions while 3 patients (11.5%) had duodenal cancer. Metastatic disease was present in 13 patients (50%). Mean ECOG status was 2 (n= 13). ERCP was unsuccessful due to an inability to cannulate the CBD (n= 3), duodenal tumour infiltration (n=10), destroyed ampulla (n=6) and inaccessible papilla (n=5). EUS-guided CBD stent placement was successful in 24 patients (92.3%). The mean CBD diameter at presentation was 19.5 mm (range 14–32) and mean distance between the bile duct and duodenum was 4.2 mm. The complication rate was 15.3% (4/26 patients). Complications included cholecystitis, stent blockage, slow bleeding and bowel perforation after a displaced stent. Median post-procedure LOS was 5.5 days. A reduction in bilirubin to <50% was observed in 19 patients (73%) by discharge. There were 2 biliary re-interventions in the group. The overall 30-day mortality rate was 38.4% (n=10) with a procedure specific mortality of 11.5% (n=3). Conclusions EUS-guided choledocho-duodenostomy is an effective and safe option to relieve jaundice in this group of patients.

Investigator initiated clinical trial to validate usefulness of specific system for endoscopic ultrasound guided hepaticogastrostomy (HG01) in malignant biliary obstruction (HG01).

Introduction:Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a novel drainage option for patients with an inaccessible papilla. Although EUS-HGS has clinical benefits in patients for whom endoscopic retrograde cholangiopancreatography (ERCP) has failed, the rates of adverse events (AEs) associated with EUS-HGS, such as bile peritonitis and stent migration, are higher than for other procedures. The development of a dedicated system for EUS-HGS is therefore desirable to reduce the rate of AEs. We developed a dedicated system for EUS-HGS (HG01 system) which is composed of a 19-gauge needle, 0.025-inch guidewire, a thin delivery system for tract dilation, and an antimigration metal stent. This study is designed to evaluate the efficacy and safety of EUS-HGS using the HG01 system in malignant biliary obstruction.Methods/design:This is a single-arm multicenter prospective study involving 40 patients across six tertiary centers in Japan. Patients with an unresectable malignant biliary obstruction in whom biliary drainage with ERCP failed, is not possible, or is very difficult will be registered in the study. The primary endpoint is the clinical success rate. The secondary endpoints are the technical success rate, procedure-related AE rate, procedure time, procedure success rate using only the HG01 system, stent patency rate, re-intervention success rate, re-intervention method, survival rate, and distance of movement of the stent position.Discussion:We expect use of the HG01 system to reduce the rate of AEs during EUS-HGS, especially bile leakage and stent migration. If the efficacy and safety of EUS-HGS using the HG01 system is confirmed in the present study, it is likely to be considered the first-choice device for use during EUS-HGS.

S1666 EUS Choledochoduodenostomy: A Novel Way to Treat Recurrent Malignant Biliary Obstruction in the Setting of an Existing Biliary and Duodenal Stent

Introduction: EUS-guided choledochoduodenostomy (EUS-CD) is an effective way to manage patients with malignant biliary obstruction and an inaccessible papilla. It involves creation of a fistula between the duodenal bulb and distal common biliary duct (CBD) using a lumen-apposing metal stent (LAMS). Data shows high technical and clinical success rates, with low adverse event rates and improved morbidity and mortality. Advantages of this approach include the ability to provide drainage to altered or inaccessible anatomy, and minimal invasiveness due to internalized drainage. We present a report of a patient with cholangitis due to recurrent biliary and gastric outlet obstruction (GOO) treated successfully with duodenal stenting and EUS-CD despite indwelling hardware. Case Description/Methods: A 71-year-old male with as history of locally invasive pancreatic adenocarcinoma presented with cholangitis and intolerance to oral intake. His prior course was complicated by GOO and biliary obstruction that required biliary fully covered self-expandable metal stent (FC-SEMS) and uncovered duodenal stent placement. Despite palliative chemotherapy, he presented 6 months later with cholangitis and imaging findings concerning for CBD stent occlusion, partial GOO and new ascites. Upper endoscopy showed significant stenosis within the duodenal stent that involved the major papilla, preventing conventional ERCP. The decision was made to evaluate for EUS biliary drainage. Presence of significant ascites precluded hepaticogastrostomy or gastrojejunostomy, however, there was an area superior to the indwelling biliary stent amenable to EUS-CDS. A 10mm x10mm LAMS was placed into the common hepatic duct with drainage of purulent fluid (Figure 1). Cholangiogram confirmed correct placement and excluded a leak. An uncovered duodenal stent was deployed through the indwelling duodenal stent and placement confirmed radiographically (Figure 1). The patient was discharged 2 days later with downtrending liver chemistries and tolerating oral intake. Discussion: Patients with combined malignant biliary and duodenal obstruction can be challenging to manage. Existing hardware complicates management even further. This case highlights the versatility of EUS biliary drainage allowing patient directed therapy with EUS-CDS in the setting of an existing biliary stent as an effective means of biliary drainage when ERCP was not possible.Figure 1.: A: occluded biliary stent B: LAMS with pigtail stents C: duodenal stent D: KUB showing stents in place.

Transluminal intrahepatic bile duct stone removal using a novel spiral basket catheter via the endoscopic ultrasound-guided hepaticogastrostomy route (with video).

Recently, endoscopic ultrasound (EUS)-guided biliary drainage has been developed as an alternative biliary drainage technique for failed endoscopic retrograde cholangiopancreatography (ERCP) or inaccessible papilla. Among the various EUS-guided biliary drainage procedures, EUS-guided hepaticogastrostomy (HGS) can be performed in patients with surgically altered anatomy. More recently, various transluminal treatments have been described after EUS-HGS, such as antegrade stone removal. In patients with hepaticojejunostomy strictures, stone extraction into the intestine might be challenging even after performing hepaticojejunostomy stricture dilation using a balloon catheter. In such cases, transluminal stone removal is considered an alternative method. With transluminal stone removal, a small stone that escapes from the conventional basket or from a balloon catheter could migrate into the branch bile ducts. The novel spiral basket catheter available in Japan. The wires form a helix shape, wherein each wire is wound counterclockwise, and the winding pitch becomes gradually tighter from the proximal portion to the tip. As the winding pitch is smaller and the wires are in closer contact with the bile duct wall as compared with conventional basket catheter, small bile duct stones can be easily captured by simply pulling back the catheter while the basket is open. In addition, even during withdrawal inside the bile duct, a high retrieval performance is assured by the special design that maintains the opening width on the top end. Therefore, transluminal stone removal using this novel basket catheter might be clinically useful, although further prospective evaluation of a larger number of cases is needed.

Antegrade Therapy for Management of Choledocholithiasis through Endoscopic Ultrasound-Guided Hepaticogastrostomy in a Patient with Surgically Altered Gastrointestinal Anatomy

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a technique used to access the biliary tree in patients with surgically altered anatomy. Additionally, development of EUS-HG fistula permits intraductal therapy, thereby preventing patients from requiring surgery or percutaneous transhepatic biliary drainage (PTBD), thus decreasing morbidity. This clinical vignette describes an 83-year-old man with a history of gangrenous cholecystitis requiring cholecystectomy, partial gastrectomy, and Roux-en-Y gastrojejunostomy who presented to an outside hospital with abdominal pain and fever and found to have cholangitis and choledocholithiasis. He underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures at an outside hospital which were unsuccessful due to an inaccessible major papilla in the setting of the patient's surgically altered anatomy. On arrival to Wake Forest, the patient underwent EUS-HG with successful biliary drainage and resolution of cholangitis. He returned for ERCP three months later with balloon sphincteroplasty, cholangioscopy, and electrohydraulic lithotripsy (EHL) performed through the existing metal stent (hepaticogastrostomy), resulting in stone fragmentation and antegrade removal with balloon sweeps. Repeat cholangioscopy post-EHL and balloon sweeps showed complete duct clearance with no residual stones. The hepaticogastrostomy stent was subsequently removed, and the patient recovered without any complications.

Which Are the Most Suitable Stents for Interventional Endoscopic Ultrasound?

Endoscopic ultrasound (EUS)-guided interventions provide easy access to structures adjacent to the gastrointestinal tract, effectively targeting them for therapeutic purposes. They play an important role in the management of pancreatic fluid collections (PFC) and bile duct (BD) and pancreatic duct (PD) drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) or gallbladder (GB) drainage. Specially designed stents and delivery systems for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. In fact, EUS-guided drainage has emerged as the treatment of choice for the management of PFC, and recent innovations such as fully covered metal stents (including lumen-apposing metal stents) have improved outcomes in patients with walled-off necrosis. Similarly, EUS-guided BD and PD drainage with specially designed stents can be beneficial for patients with failed ERCP due to an inaccessible papilla, gastric outlet obstruction, or surgically altered anatomy. EUS-guided GB drainage is also performed using dedicated stents in patients with acute cholecystitis who are not fit for surgery. Although the field of dedicated stents for interventional EUS is rapidly advancing with increasing innovations, the debate on the most appropriate stent for EUS-guided drainage has resurfaced. Furthermore, some important questions remain unaddressed, such as which stent improves clinical outcomes and safety in EUS-guided drainage. Herein, the current status and problems of the available stents are reviewed, including the applicable indications, long-term clinical outcomes, comparison between each stent, and their future prospects.

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery.

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery.

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.

Endoscopic ultrasound-guided rendezvous in benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire.

Background and study aims The aim of this study was to assess the efficacy and safety of endoscopic ultrasound-guided rendezvous (EUS-RV) for benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire. Patients and methods Patients who underwent EUS-RV after failed biliary or pancreatic cannulation for benign disorder were candidates for this study. For EUS-RV, a 22-gauge needle and a 0.018-inch guidewire were used. Inclusion criteria were unsuccessful biliary or pancreatic cannulation for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with benign biliary or pancreatic obstruction. Exclusion criteria included malignant biliary or pancreatic obstruction, inaccessible papilla due to surgically altered upper gastrointestinal anatomy or duodenal stricture, and previous sphincterotomy and/or biliary stent placement. The primary outcome was the technical success rate of biliary or pancreatic cannulation, and the secondary outcome was the rate of adverse events. Results Thirty-one patients were evaluated. The overall technical success rate was 80.6 % (81.5 % in biliary and 75 % in pancreatic cases). Adverse events (AEs) were identified in 12.9 % of patients, including one with biliary peritonitis, one with abdominal pain and one with severe pancreatitis plus pneumomediastinum. Only one of the AEs (3.3 %) was directly related to the rendezvous procedure. Conclusions EUS-RV may be a safe and feasible salvage method for unsuccessful cannulation for benign disorders. Use of a 22-gauge needle with a 0.018-inch guidewire may be the first option for benign pathology.

EUS-guided antegrade procedures.

Endoscopic transpapillary procedure, so-called ERCP-related procedure, should be considered as the first-line treatment method for biliary disorders such as acute cholangitis, obstructive jaundice, or choledocholithiasis because of its less invasiveness and lower risk of adverse events than other techniques despite the risk of post-ERCP pancreatitis.[1,2,3,4,5] However, ERCP-related procedure is not always successfully accomplished, even when performed by skilled endoscopists, in cases of inability of selective biliary cannulation because of the presence of intradiverticular papillae, a long narrow distal segment of the distal bile duct, or inaccessible papilla because of gastric outlet obstruction or surgically altered anatomy (SAA) even using balloon enteroscope.[6,7] Recently, in such cases, EUS-guided biliary drainage (EUS-BD) approach has been developed and reported as a novel useful alternative technique when standard ERCP-related procedure has failed.[8,9,10,11,12,13,14] As regards EUS-BD for obstructive jaundice due to malignant biliary stricture, EUS-BD is divided into several techniques depending on the approach route.[15] At present, there is no universal consensus on the optimal strategy for which the EUS-BD technique should be selected. Thus far, the selection of the EUS-BD approach depends on the patient's condition, which may involve the presence of gastric outlet obstruction, the site of biliary obstruction, the anastomosis after surgical intervention, or the preference of the endoscopist.[16] In several EUS-BD techniques, EUS-guided choledochoduodenostomy (EUS-CDS) and EUS-guided hepaticogastrostomy (EUS-HGS) are common mostly in patients with malignant diseases at the end stage of disease because these techniques are simple. However, bile flow in EUS-CDS or EUS-HGS is not physiological, resulting in short stent patency rather than retrograde biliary metal stent placement across the stricture site by ERCP. Furthermore, as there are as yet no commercially available dedicated metal stents for EUS-CDS or EUS-HGS around the world, a braided-type covered metal stent is conventionally used on EUS-CDS or EUS-HGS, which has some concern about stent misplacement or migration due to its high shortening rate.[17] Therefore, EUS-guided antegrade stenting (EUS-AGS) has been developed and reported as a useful option of EUS-BD because of the theoretical physiological bile flow in patients with inaccessible ampulla.[18] Moreover, EUS-antegrade intervention (EUS-AI) for benign biliary diseases in patients with surgically altered anatomy that is an antegrade treatment via the approach route created by EUS-HGS has been developed by application of EUS-AGS.[19] Herein, we describe technical details regarding such EUS-guided antegrade procedure for malignant and benign biliary diseases.

Drainage of the right liver under EUS guidance: A bridge technique allowing drainage of the right liver through the left liver into the stomach or jejunum.

Background and Objective:EUS-guided biliary drainage is now comparable to percutaneous drainage. This technique can be used in cases of complex drainage of the hilum, mainly for salvage therapy to drain the left liver. In cases of inaccessible papilla or altered anatomy, EUS-guided biliary drainage for hilar stenosis of the liver could be used as the first approach. However, this technique has limited applicability for the right liver. In this feasibility study, we reported drainage of the right liver using the bridge technique and hepaticogastrostomy.Patients and Methods:This retrospective study was based on a prospective registry from January 2013 to February 2017. Patients with inaccessible papilla due to altered anatomy or duodenal invasion and drainage under EUS guidance and bridge technique without previous biliary drainage were included in the study. The bridge technique was used to place an uncovered biliary stent between the right and left liver. The left liver was drained with a hepaticogastrostomy.Results:Twelve patients were included in the study. Stenosis was Type II for nine, IIIA for two, and Type IV for one patient. Technical and clinical success was 100% and 83%, respectively. Morbidity was 33% (four patients), including three with abdominal pain managed conservatively and one with a percutaneous salvage drainage. Postoperative mortality was 8% (uncontrolled sepsis). The mean survival was 6 months. Chemotherapy could be administered in 70% (seven) patients in cases of clinical success.Conclusion:The bridge technique under EUS guidance could be a first alternative for draining malignant hilar stenosis in cases of the inaccessible papilla.

Endoscopic Ultrasound-Guided Choledochoduodenostomy for Biliary Drainage in Patients with Lower End Common Bile Duct Block: A Single-Center Experience

Abstract Objective: Endoscopic ultrasound (EUS)-guided biliary drainage is evolving as an alternative technique in patients with failed endoscopic retrograde cholangiopancreatography. The objective of this study was to find out the outcome of EUS-guided choledochoduodenostomy in patients with malignant mid and lower end biliary obstruction with inaccessible papilla presenting at our center. Methods: The present study was a single-center prospective observational study. Data of all the patients who underwent choledochoduodensotomy from January 2014 to December 2015 were recorded. Outcome measures were technical success and clinical success. Technical success was defined as successful placement of stent in the biliary system; clinical success was defined as 50% reduction in bilirubin at 2 weeks. Complications during the procedure and follow-up were recorded. Results: A total of 10 patients underwent EUS-guided choledochoduodenostomy. Cause of biliary obstruction was pancreatic cancer in eight patients, two patients had carcinoma gallbladder with mid-common bile duct (CBD) block due to compression by metastatic lymph nodes, and one patient had ampullary carcinoma. Mean bilirubin value was 16.4 mg/dL (±3.2 mg/dL). Technical and clinical success were 100% and 90%, respectively. No immediate procedure-related complication was noticed. Two patients had stent migration during the follow-up. Conclusion: EUS-guided choledochoduodenostomy is an effective and safe alternative for rescuing biliary drainage in patients with mid and lower end malignant CBD block with inaccessible papilla.

Endoscopic ultrasound-guided biliary and vesicular drainage: Low complication rate in a tertiary center

Background:Endoscopic ultrasound (EUS) allows bile duct drainage in case of endoscopic retrograde cholangiopancreatography (ERCP) failure or inaccessible papilla, during the same anesthetic time, as an alternative to delayed radiological drainage. Our study aims were to review indications, techniques, and early complications (<7 days) of biliary drainage by EUS as a second-line treatment after ERCP failure, including inaccessible papilla and failed ERCP.Methods:This was a retrospective evaluation carried out between 2002 and 2016.Results:Out of >8400 ERCPs performed during this period, 31 patients (68 years range 14–92) were included. 66% (19/29) had failed bile duct drainage due to neoplastic infiltration and the others had inaccessible papilla: roux-en-Y limb (3/10), duodenal stenosis (6/10), or stent (1/10). 65% were drained transgastrically and 35% through the bulb. Drainage was achieved by placing a transmural stent in 79% of cases, “rendezvous” in 14%, and anterograde access in 7%. Two gallbladder drainages were performed in inoperable patients with acute cholecystitis. Average procedural time was 68 min. There were four early complications, including pneumoperitoneum before CO2 use, three stent migrations, or malposition, all of which treated endoscopically.Conclusions:EUS-guided biliary and vesicular drainage can be safely performed even in low rates of ERCP failures.

Outcome of endoscopic ultrasound-guided choledochoduodenostomy as rescue treatment after failed endoscopic retrograde cholangiopancreatography in mid and lower end common bile duct block

Background and Objectives:Endoscopic ultrasound (EUS)-guided biliary drainage is novel technique for biliary drainage after failed ERCP. The aim of the present study is to report the outcomes of EUS-guided biliary drainage after failed ERCP due to inaccessible papilla due to duodenal infiltration.Methods:Data of all the patients who underwent choledochoduodenostomy form April 2014 to September 2016 were collected. Suprapancreatic common bile duct (CBD) was punctured transduodenally with a 19-gauge needle, needle tract was dilated using 6F cystotome, and a fully covered self-expanding metal stent was placed into the CBD. Complications during procedure and follow-up were recorded.Results:Ten patients underwent EUS-guided choledochoduodenostomy. Seven patients had pancreatic cancer, two had carcinoma gall bladder with mid CBD block by metastatic lymph nodes, and one had ampullary carcinoma. Mean bilirubin was 16.4 mg/dL (± 3.2 mg/dL). Procedure could be performed successfully in all ten patients. Jaundice improved in all the patients, except one who had liver metastasis. No procedure-related complication was noticed. Bilirubin decreased to 1.8 mg/dl (± 1.4 mg/dL) at 1-month follow-up. After a mean follow-up of 8 months (± 2 months), survival was 70%, three patients died of underlying malignancy, one patient had stent migration in duodenal lumen, which was taken out, and plastic stent placed through the patent choledochoduodenal fistula.Conclusion:EUS-guided choledochoduodenostomy is a safe and effective alternative biliary drainage in patients with mid and lower end malignant CBD block.

Indications for endoscopic ultrasonography (EUS)-guided biliary intervention: Does EUS always come after failed endoscopic retrograde cholangiopancreatography?

Endoscopic ultrasonography-guided biliary drainage (EUS-BD), first reported as an alternative to percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP), is increasingly reported as a primary procedure without failed ERCP. The present study aims to evaluate the outcomes of therapeutic biliary ERCP and to compare the safety and effectiveness of primary EUS-BD with those of ERCP, rescue EUS-BD and PTBD. We retrospectively studied therapeutic biliary ERCP as well as subsequent rescue PTBD and EUS-BD. Additionally, indications, safety and technical success of primary EUS-BD were evaluated. Between August 2013 and September 2015, a total of 520 therapeutic biliary ERCP with a native papilla were analyzed. We encountered 23 cases with inaccessible papilla and 22 cases with failed cannulation, which were rescued by 21 PTBD, 16 EUS-BD and two repeat ERCP. Additionally, 40 primary EUS-BD were carried out during the same period as a result of 10 recurrent cholangitis cases after transpapillary drainage, five outside failed cannulation, four altered anatomy, two history of ERCP-related adverse events (AE), two technical difficulties in stenting under enteroscopy-assisted ERCP and 17 on study protocol. Technical success and AE rates were 95.6% and 14.5% in ERCP, 90.5% and 33.3% in rescue PTBD, 93.8% and 18.8% in rescue EUS-BD, and 95.0% and 22.5% in primary EUS-BD, respectively. Rescue EUS-BD was used in 3.1% among all ERCP. Given the comparable technical success and AE rates of both primary and rescue EUS-BD, primary EUS-BD without failed ERCP can be a treatment option if it provides advantages over ERCP.

Optimal biliary access point and learning curve for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting.

Background:Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) with transmural stenting has increased for biliary decompression in patients with an inaccessible papilla, the optimal biliary access point and the learning curve of EUS-HGS have not been studied. We evaluated the optimal biliary access point and learning curve for technically successful EUS-HGS.Methods:129 consecutive patients (male n = 81, 62.3%; malignant n = 113, 87.6%) who underwent EUS-HGS due to an inaccessible papilla were enrolled. EUS finding and procedure times according to each needle puncture attempt in EUS-HGS were prospectively measured. Learning curves of EUS-HGS were calculated for two main outcome measurements (procedure time and adverse events) by using the moving average method and cumulative sum (CUSUM) analysis, respectively.Results:A total of 174 EUS-HGS attempts were performed in 129 patients. The mean number of needle punctures was 1.35 ± 0.57. Using the logistic regression model, bile duct diameter of the puncture site ⩽ 5 mm [odds ratio (OR) 3.7, 95% confidence interval (CI): 1.71–8.1, p < 0.01] and hepatic portion length [linear distance from the mural wall to the punctured bile duct wall on EUS; mean hepatic portion length was 27 mm (range 10–47 mm)] > 3 cm (OR 5.7, 95% CI: 2.7–12, p < 0.01) were associated with low technical success. Procedure time and adverse events were shorter after 24 cases, and stabilized at 33 cases of EUS-HGS, respectively.Conclusions:Our data suggest that a bile duct diameter > 5 mm and hepatic portion length 1 cm to ⩽ 3 cm on EUS may be suitable for successful EUS-HGS. In our learning curve analysis, over 33 cases might be required to achieve the plateau phase for successful EUS-HGS.

Temporary duodenal stenting as a bridge to ERCP for inaccessible papilla due to duodenal obstruction: a retrospective study.

Background and study aims: Duodenal obstruction may prevent performance of endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasonograhy-guided biliary access (EUS-BD) are alternative treatments but are associated with a higher morbidity and mortality rate. The aim of the study is to report overall technical success rate and clinical outcome with deployment of temporary fully or partially covered self-expanding duodenal stent (pc/fcSEMS) as a bridge to ERCP in case of inaccessible papilla due to duodenal strictures. Patients and methods: This retrospective study included 66 consecutive patients presenting with a duodenal stricture impeding the ability to perform an ERCP. Provisional duodenal stenting was performed as a bridge to ERCP. A second endoscopic session was performed to remove the provisional stent and to perform an ERCP. Afterward, a permanent duodenal stent was delivered if necessary. Results: Sixty-six duodenal stents (17 pcSEMS and 49 fcSEMS) were delivered with a median indwelling time of 3.15 (1 – 7) days. Two migrations occurred in the pcSEMS group, 1 of which required lower endoscopy for retrieval. No other procedure-related complications were observed. At second endoscopy a successful ERCP was performed in 56 patients (85 %); 10 patients (15 %) with endoscopic failure underwent PTBD or EUS-BD. Forty patients needed permanent duodenal stenting. Conclusions: Provisional removable covered duodenal stenting as a bridge to ERCP for duodenal obstruction is safe procedure and in most cases allows successful performance of therapeutic ERCP. This technique could be a sound option as a step up approach before referring such cases for more complex techniques such as EUS-BD or PTBD.