Endoscopic ultrasound-guided anterograde treatment of biliary stones following gastric bypass

Abstract

Endoscopic treatment of bile duct stones in gastric bypass patients is challenging. We describe a novel method involving endoscopic ultrasound (EUS)-guided anterograde interventions. After prior experience with EUS-guided rendezvous endoscopic retrograde cholangiopancreatography (ERCP) and direct EUS-guided anterograde stenting for malignant biliary obstruction, we have attempted EUS-guided treatment of biliary stones as first-line therapy following gastric bypass. Our approach involves: (i) EUS-fine needle aspiration (FNA) puncture into an intrahepatic bile duct; (ii) EUS-guided cholangiography; (iii) guide wire advancement across the ampulla; (iv) catheter dilation of the transhepatic-transgastric access tract; (v) anterograde balloon sphincteroplasty; and (vi) anterograde advancement of stones across the ampulla using a balloon catheter. We reviewed outcomes and complications of this technique. Six patients with previous Roux-en-Y gastric bypass were referred for treatment of symptomatic choledocholithiasis. EUS-guided transhepatic puncture and cholangiography was successful in 100 %, and revealed choledocholithiasis in all patients. Tract dilation, anterograde balloon sphincteroplasty, and stone extraction were successful in four (67 %). Anterograde sphincteroplasty failed in two patients due to inability to advance the transhepatic dilation catheters. In both cases, wires were advanced down the afferent limb, and rendezvous ERCP using double-balloon enteroscopy was successful. Five patients experienced no complications. One patient in whom EUS anterograde therapy failed due to difficulty in advancing the transhepatic dilation catheter, developed a subcapsular hepatic hematoma. This was managed conservatively. Direct EUS-guided treatment of biliary stones after gastric bypass appears safe and feasible. Further studies are needed to confirm the safety and efficacy of this technique.

Endoscopic ultrasonography-guided transhepatic antegrade stone removal in patients with surgically altered anatomy: case series and technical review (with videos)

“…In the previous studies by Weilert et al. and Iwashita et al. , there was no precise information regarding the size, number, diameter of the stone and the shape of the bile duct.…”

Endoscopic Ultrasound-Guided Pancreatobiliary Endoscopy in Surgically Altered Anatomy

“…Throughout the entire procedure, it is important to maintain the original echoendoscope tip position used when the bile duct was accessed with the FNA needle and close apposition of the tip with the intestinal lumen by using both ultrasound and fluoroscopic guidance, especially if using an oblique viewing scope. The main concern with this antegrade approach is bile leak from the temporary enterobiliary fistula [36-38]. Placement of a second transhepatic stent or a nasobiliary drain following antegrade balloon dilation is optional, and it is unclear whether these additional steps decrease bile leak from the transmural puncture site.…”

“…A few case series reviewed the use of EUS-guided antegrade biliary drainage in patients with both normal anatomy and SAA [36,37,39,40]. In these small studies, the technical success rate ranged from 67% to 100% for the entire cohort, with a clinical success rate of approximately 78%.…”

“…In these small studies, the technical success rate ranged from 67% to 100% for the entire cohort, with a clinical success rate of approximately 78%. Complications occurred in about 5% of cases and included abdominal pain, mild pancreatitis, and hepatic subcapsular hematoma [36,38,41-43]. …”

Endoscopic Ultrasound–Assisted Pancreaticobiliary Access

“…The authors reported technical success of EUS-guided anterograde balloon sphincteroplasty and anterograde stone extraction in 4 out of 6 patients. 24 Park do and colleagues 25 have described a case report of EUS-guided transhepatic anterograde balloon dilation for a benign bilioenteric anastomotic stricture. The available data on EUS-guided downstream transductal interventions are summarized in Table 2.…”