A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction

Abstract

Background and study Aims: Selective biliary cannulation is unsuccessful in 5 % to 10 % of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard, but endoscopic ultrasound guided rendezvous (EUSr) have been increasingly used for biliary decompression in this patient population. Our aim was to compare the initial success rate, long-term efficacy, and safety of PBD and EUSr in relieving MDBO after failed ERC Patients and methods: A retrospective study involving 50 consecutive patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008 – 2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002 – 2008). Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates after biliary decompression. Results: The mean age at presentation was 66.5 (± 12.6 years), 28 patients (54.9 %) were female. The etiology of MDBO was pancreaticobiliary malignancy in 44 (88 %) and metastatic disease in 6 (12 %) cases. Biliary drainage was technically successful by EUSr in 19 (76 %) cases and by PBD in 25 (100 %) (P = 0.002). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (P = 0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (P = 0.001). Conclusions: Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful, patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions.Meeting presentations: Annual Digestive Diseases Week 2015

Interventional radiology-operated endoscopy-assisted retrograde transnasal placement of a retrievable transhepatic covered biliary stent

“…Case reports from a single group have described utilization of a custom-fabricated system in benign biliary strictures, but this is cost-prohibitive without widespread utilization [4] . Rendezvous procedures performed with gastroenterology have been described, but require resource coordination and planning, which may be prohibitive [5] . Biodegradable stents may also serve similar purposes.…”

Current Endoscopic Management of Malignant Biliary Stricture

“…In some situations, PTCD has been used as part of a rendezvous endoscopic approach. A comparison in 2016 between EUS-guided and PTCD rendezvous drainage after the failure of primary ERCP in MDBO showed that EUS rendezvous had a significantly lower success rate than the PTCD rendezvous [36]. However, successful EUS rendezvous offered a significantly shorter post-procedure hospital stay and fewer follow-up biliary interventions.…”

“…Another alternative approach to EUS-HGS is EUS-guided choledochoduodenostomy (EUS-CDS) [89], which offers management methods other than PTCD. Due to the high rate of complications, EUS-guided biliary drainage has served as an alternative approach over the last two years; however, some encouraging results have shown a similar safety profile and procedure success rate and even better stent patency during that same timeframe [36,37,90].…”

Endoscopic palliation of biliary obstruction

“…Biliary stenting through ERCP may also be unsuccessful due to inability to cannulate the bile duct secondary to complex altered surgical anatomy related to prior surgeries (ie, Whipple procedure, Roux‐en‐Y gastrojejunostomy), tumor‐related alterations in the periampullary anatomy, or high‐grade strictures that preclude biliary access in a retrograde approach . Although percutaneous drainage should be considered in this situation, the morbidity and decreased quality of life associated with external drainage has led to the development of alternative approaches with the aim of achieving internal biliary drainage when initial ERCP is unsuccessful for MBTO.…”

“…These techniques aim to establish internal biliary drainage during a single procedure performed by an advanced endoscopist. Initial randomized control and comparative studies of EUS‐guided biliary drainage to percutaneous drainage are promising and have demonstrated that EUS‐guided biliary drainage has similar rates of success with decreased rate of adverse events, hospitalization length, and fewer follow‐up biliary procedures compared to percutaneous drainage…”