Endoscopic ultrasound-guided hepaticogastrostomy versus percutaneous transhepatic drainage for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography: a retrospective expertise-based study from two centers

Abstract

Background:Percutaneous transhepatic biliary drainage (PTBD) is widely performed as a salvage procedure in patients with unresectable malignant obstruction of the common bile duct (CBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) or in case of surgically altered anatomy. Endoscopic ultrasound-guided hepaticogastrostomy (EU-HGS) is a more recently introduced alternative to relieve malignant obstructive jaundice. The aim of this prospective observational study was to compare the outcome, efficacy and adverse events of EU-HGS and PTBD.Methods:From April 2012 to August 2015, consecutive patients with malignant CBD obstruction who underwent EU-HGS or PTBD in two tertiary-care referral centers were included. The primary endpoint was the clinical success rate. Secondary endpoints were technical success, overall survival, procedure-related adverse events, incidence of adverse events, and reintervention rate.Results:A total of 51 patients (EU-HGS, n = 31; PTBD, n = 20) were included. Median survival was 71 days (range 25–75th percentile; 30–95) for the EU-HGS group and 78 days (range 25–75th percentile; 42–108) for the PTBD group (p = 0.99). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 (86%) of 31 patients in the EU-HGS group and in 15 (83%) of 20 patients in the PTBD group (p = 0.88). There was no difference in adverse events rates between the two groups (EU-HGS: 16%; PTBD: 10%) (p = 0.69). Four deaths within 1 month (two hemorrhagic and two septic) were considered procedure related (two in the EU-HGS group and two in the PTBD group). Overall reintervention rate was significantly lower after EU-HGS (n = 2) than after PTBD (n = 21) (p = 0.0001). Length of hospital stay was shorter after EU-HGS (8 days versus 15 days; p = 0.002).Conclusions:EU-HGS can be an effective and safe mini invasive-procedure alternative to PTBD, with similar success and adverse-event rates, but with lower rates of reintervention and length of hospitalization.

Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent through an uncovered metal duodenal stent

“…Endoscopic ultrasound guided biliary drainage (EUS-BD) has been increasingly used as an alternative to percutaneous transhepatic biliary drainage after failed ERCP 2 3 . EUS-CD and EUS-HGS have been reported to have similar efficacity 4 .…”

An Improved Method of Percutaneous Transhepatic Biliary Drainage Combining Ultrasound-Guided Bile Duct Puncture with Metal Stent Implantation by Fluoroscopic Guidance and Endoscopic Visualization as a One-Step Procedure: A Retrospective Cohort Study

“…3,4,7,8 A detailed description of the PTBD procedure was only reported in four out of six studies. 3,[5][6][7] PTBDs which were performed with ultrasound guidance had fewer adverse events (10-25%) than PTBDs which only used fluoroscopic guidance (31-46%). In the study from Artifon et al, 6 4 of the 12 patients underwent external drainage catheter insertion before metal stent implantation.…”

“…In the study from Sharaih et al, 8 it was not reported how many metal stents were inserted, and how many benign and malign diseases were mixed and not differentiated, which makes any comparison with EUS-BD very difficult. Lastly, in the study from Sportes et al, 7 the external drainage was left after metal stent implantation and removed some days later when stent implantation was clinically successful. This further procedure may not be necessary when stent release is visualized by endoscopic luminal guidance as discussed above.…”

“…Endoscopic ultrasound-guided biliary drainage (EUS-BD) was first described in 2001 by Giovannini et al 2 and is now a rapidly evolving method for biliary drainage in patients with malignant bile duct obstruction in this setting. A recent meta-analysis about efficacy and safety in EUS-BD in comparison with PTBD included six completely published studies [3][4][5][6][7][8] and three abstracts with 483 patients and showed better clinical success, fewer post-procedural adverse events, and a lower rate of re-interventions for EUS-BD. 9 The authors concluded that EUS-BD may be preferred to PTBD if adequate endoscopic expertise and logistics are available.…”

A review of endoscopic ultrasound guided endoscopic retrograde cholangiopancreatography techniques in patients with surgically altered anatomy

“…There is no significant difference in the overall technical success and safety of transhepatic or transduodenal access (42,43). In comparison to percutaneous biliary drainage EUS-BD has been shown in multiple studies to have higher clinical success rates, lower rates of adverse events and reintervention, along with lower hospital length of stay and costs (5,(44)(45)(46). When comparing EUS-BD to EA-ERCP in an international comparative study, the technical and success was higher for EUS-BD (98% vs. 65% and 88% vs. 59%), with shorter procedure times (55 vs. 95 min); although length of hospital stay and adverse events were more common in the EUS-BD (47,48).…”