Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing, self-expandable fully covered metal stent for palliative biliary drainage

Abstract

In addition to the poor prognosis associated with pancreatic adenocarcinoma, it can also lead to several other conditions including obstructive jaundice that can affect a patient's quality of life. This is a major concern in non-operative patients where palliation is considered the main therapeutic goal. Traditionally, there are several ways to pursue palliative biliary drainage including endoscopic methods, a variety of surgical procedures, and percutaneous techniques. Generally, endoscopic methods such as endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stent placement are considered first-line therapies. Unfortunately, ERCP is not always possible due to several potential reasons. Although endoscopic ultrasound-guided biliary puncture has been well described for several years, there are limitations to its usefulness in biliary drainage, in part due to complication concerns. However, more recently a lumen-apposing, self-expandable fully covered metal stent has been employed for such situations. We describe two cases in which this type of stent was used in patients for palliative biliary drainage in pancreatic adenocarcinoma where standard ERCP was not feasible. In both cases, stent deployment was successful without immediate complications related to the procedure or the stent. Furthermore, the main goal of these therapies was palliation and in both cases the patient chose this procedure for quality of life reasons. In the future, randomized trials are needed to better define the long-term effectiveness and safety of these stents compared to more standard therapies.

Endoscopic Ultrasound Guided Choledocho-Enterostomy by Using Lumen Apposing Metal Stent in Patients with Failed Endoscopic Retrograde Cholangiopancreatography: A Literature Review

“…In our review, we included 10 case reports – 2 from Spain [16, 20], 3 from Japan [17-19], 4 from the United States [14, 15, 21, 22], and 1 from Italy [13]. In addition, we included 2 case series – one of which comes from Italy [23] while the other one was a multicenter study from Germany, Denmark, Italy, and Spain [24].…”

“…For each patient there was either a failure to achieve biliary cannulation [13, 14, 16, 17, 20, 24, 25] or the ERCP in itself was technically challenging due to duodenal obstruction [14, 15, 21, 23-25] or altered GI anatomy from prior surgery [18, 19, 22]. Even single-balloon enteroscopy-assisted ERCP [18, 22] and biliary cannulation via rendezvous approach [14, 20] failed in 4 cases. Majority of the patients had preferentially selected EUS-BD via CD over PTBD approach.…”

“…Once the dilated extra hepatic biliary was identified on the EUS, a 19 G needle was used to puncture it [14, 20-22, 24, 25]. The position was then confirmed either by free outward flow of bile or by contrast infusion and its visualization under the fluoroscopy.…”

“…The position was then confirmed either by free outward flow of bile or by contrast infusion and its visualization under the fluoroscopy. Needle was followed by passage of a guide wire, which was either 0.025 inch [25] or 0.035 inch [14, 21, 24] thick. This was followed by a dilator, which was a balloon, a catheter, or a cystostome depending on the endoscopist’s preference and availability [14, 15, 20-22, 24].…”

“…Although the majority of authors mention the presence of a dilated biliary tree, only 4 studies actually reported the true size [13, 14, 24, 25]. Seventy-nine patients from these 4 studies had a mean/median bile duct size of more than 15 mm [13, 14, 24, 25].…”