EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results

doi:10.1016/j.gie.2011.07.054

Gastrointestinal Endoscopy

Volume 74, Issue 6, December 2011, Pages 1276-1284

https://doi.org/10.1016/j.gie.2011.07.054 Get rights and content

Background

EUS-guided biliary drainage (EUS-BD) has been proposed as an effective alternative for percutaneous transhepatic biliary drainage (PTBD) after failed ERCP. To date, the risk factors for adverse events and long-term outcomes of EUS-BD with transluminal stenting (EUS-BDS) have not been fully explored.

Objective

To evaluate risk factors for adverse events and long-term outcomes of EUS-BDS.

Design

Prospective follow-up study.

Setting

Tertiary-care academic center.

Patients

This study involved 57 consecutive patients with malignant or benign biliary obstruction undergoing EUS-BDS after failed ERCP.

Intervention

EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy with transluminal stenting (EUS-CDS).

Main Outcome Measurements

Risk factors for postprocedure and late adverse events and clinical outcomes of EUS-BDS.

Results

The overall technical and functional success rates, respectively, in the EUS-BDS group were 96.5% (intention-to-treat, n = 55/57) and 89% (per-protocol, n = 49/55). Postprocedure adverse events developed after EUS-BDS in 11 patients (20%, n = 11/55). This included bile peritonitis (n = 2), mild bleeding (n = 2), and self-limited pneumoperitoneum (n = 7). In multivariate analysis, needle-knife use was the single risk factor for postprocedure adverse events after EUS-BDS (odds ratio 12.4; P = .01). A late adverse event in EUS-BDS was distal stent migration (7%, n = 4/55). The mean stent patencies with EUS-HGS and EUS-CDS were 132 days and 152 days, respectively.

Limitations

Single-operator performed, nonrandomized study.

Conclusion

EUS-HGS and EUS-CDS may be relatively safe and can be used as an alternative to PTBD after failed ERCP. Both techniques offer durable and comparable stent patency. The use of a needle-knife for fistula dilation in EUS-BDS should be avoided if possible.

Section snippets

Patients

From June 2008 to May 2010, a total of 2589 ERCPs were carried out in a 2600-bed, tertiary-care referral hospital by a single experienced endoscopist (D.H.P.). In this study period, a total of 1423 cases required biliary decompressions for benign or malignant biliary obstruction. Of the 1423 patients, 60 consecutive patients (4.2%, 51 malignant biliary obstructions and 9 benign biliary obstructions) were candidates for alternative techniques for biliary decompression because of failed ERCP. In

Outcomes of EUS-BDS

The overall technical success rate of EUS-BDS was 96.5% (55/57, analyzed in an intention-to-treat fashion; 31 EUS-HGS and 26 EUS-CDS; 51 malignant and 6 benign biliary obstructions). In malignant biliary obstruction (n = 51), the EUS-guided rendezvous technique was not routinely attempted initially, but conversion to this technique was performed in 2 patients with pancreatic cancer during the EUS-CDS procedure because of insufficient bile duct dilatation for transluminal stenting on EUS-guided

Discussion

To date, EUS-BD has comprised EUS-HGS, EUS-CDS, and rendezvous techniques. EUS-HGS and EUS-CDS may have advantages over the EUS-guided rendezvous technique. First, EUS-HGS can be performed on patients with surgically altered anatomy or duodenal invasion.2, 3, 6 A major limitation of the rendezvous technique is that it can be attempted only in patients in whom the papilla is accessible by endoscopy.⁶ Second, for the EUS-guided rendezvous technique, a guidewire should traverse the major duodenal

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Cited by (241)

Utilization of a Small-Caliber Balloon Dilator for Endoscopic Ultrasound-Guided Hepaticogastrostomy Creation: Case Series
2024, Techniques and Innovations in Gastrointestinal Endoscopy
Endoscopic Management of Malignant Biliary Obstruction
2024, Gastrointestinal Endoscopy Clinics of North America
Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis
2023, Gastrointestinal Endoscopy
Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.
A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.
One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I² = 77.5%).
Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.
Endoscopic ultrasound guided biliary interventions
2022, Best Practice and Research: Clinical Gastroenterology
Citation Excerpt :
Park et al. evaluated risk factors for adverse events associated with EUS-BD in 57 consecutive patients and observed a significant association of post-procedure adverse events with fistula dilation using a needle-knife (NK) electrocautery compared with graded dilation (9/27 [33%] vs 2/28 [7%], p = 0.02). They recommended avoiding of NK in EUS-BD [56]. Honjo et al. compared ultra-tapered mechanical (n = 26) and electrocautery (n = 23) (control) dilators for fistula dilation during EUS-HGS.
Endoscopic Retrograde Cholangiopancreatography (ERCP), even in expert hands, may fail in 5–10% of cases, especially in cases of papillary infiltration, malignant gastric outlet obstruction, or surgically altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has represented the traditional rescue therapy, despite associated with high rate of adverse events, need for re-interventions and an inferior quality of life. The evolution of Endoscopic Ultrasound (EUS) from a diagnostic to a therapeutic tool offers an effective and safe alternative for internal biliary drainage (BD) into the stomach or the duodenum. EUS-BD is reported to have similar or even improved efficacy and increased safety when compared to PTBD and can be performed in the same session of a failed ERCP.
This review summarizes technical aspects of intra-hepatic and extra-hepatic EUS-BD (including hepatico-gastrostomy, choledocho-duodenostomy and rendezvous) together with current evidence and future perspectives that steadily cements EUS-BD's place in multidisciplinary management of bilio-pancreatic diseases.
Endoscopic Ultrasound–Guided Biliary Interventions
2022, Gastrointestinal Endoscopy Clinics of North America
Citation Excerpt :
Several stents have been designed specific to EUS therapies, which have been summarized in Tables 3 and 4. alOutcomes and complications in EUS-BD have been well documented in sever large studies as summarized in Table 5.21,23–25,29–40 EUS-BD has a similar profile of adverse events to ERCP.
Relief of jaundice in malignant biliary obstruction: When should we consider endoscopic ultrasonography-guided hepaticogastrostomy as an option?
2022, Hepatobiliary and Pancreatic Diseases International
Since it was first described in 2001, endoscopic ultrasonography-guided biliary drainage (EUS-BD) has emerged as an alternative procedure for achieving an endoscopic internal drainage in case of endoscopic retrograde cholangiopancreatography (ERCP) failure. Biliary drainage can be achieved by either a transduodenal extrahepatic approach through EUS-guided choledochoduodenostomy (EUS-CDS), or a transgastric intrahepatic approach, namely EUS-guided hepaticogastrostomy (EUS-HGS) which already holds a remarkable place in the treatment of patients with malignant biliary obstruction.
For this review we did a comprehensive search of PubMed/MEDLINE from inception to May 31, 2021 for papers with a significant sample size (at least 20 patients enrolled) dealing with EUS-HGS. Data on technical success, clinical success and rate of adverse events were collected.
A total of 22 studies with different design, comprising 874 patients, were included. Technical success was achieved in about 96% of cases (ranging from 65% to 100%). Clinical success was obtained in almost 91% of cases (ranging from 76% to 100%). Overall rate of adverse events was 19% (ranging from 0% to 35%). Abdominal pain, self‐limiting pneumoperitoneum, bile leak, cholangitis, bleeding, perforation and intraperitoneal migration of the stent were the most common.
Despite both safety and efficacy profile, at the moment HGS still remains a challenging procedure at every single step and must therefore be conducted by a very experienced endoscopist in interventional EUS and ERCP procedures, who is able to deal with the possible severe adverse events of this procedure. A rapid introduction in clinical practice of dedicated devices is desiderable.

View all citing articles on Scopus

: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr Park at [email protected].

: See CME section; p. 1376.

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Original articleClinical endoscopyEUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Patients

Outcomes of EUS-BDS

Discussion

Tech Vasc Interv Radiol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Lancet

Gastrointest Endosc

Diagnostic endoscopic retrograde cholangiopancreatography

Endoscopy

EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos)

Gastrointest Endosc

Original article
Clinical endoscopy
EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results