EUS-guided biliary drainage or enteroscopy-assisted ERCP in patients with surgical anatomy and biliary obstruction: an international comparative study

Abstract

Background and study aims: How enteroscopy-assisted ERCP (e-ERCP) and endoscopic ultrasound-guided biliary drainage (EUS-BD) compare in patients with surgically altered upper gastrointestinal anatomy is currently unknown. The aims of this study were to compare efficacy and safety of both techniques and study predictors of these outcomes. Patients and methods: This was an international, multicenter comparative cohort study at 10 tertiary centers. Outcomes data included technical success (biliary access with cholangiography and stent placement [when indicated]), clinical success (resolution of biliary obstruction) and adverse events (AEs) (graded according to the ASGE lexicon). Results: A total of 98 patients underwent EUS-BD (n = 49) or e-ERCP (n = 49). Technical success was achieved in 48 (98 %) patients in the EUS-BD group as compared to 32 (65.3 %) patients in the e-ERCP group (OR 12.48, P = 0.001). Clinical success was attained in 88 % of patients in EUS-BD group as compared to 59.1 % in the e-ERCP group (OR 2.83, P = 0.03). Procedural time was significantly shorter in the EUS-BD group (55 min vs 95 min, P < 0.0001). AEs occurred more commonly in the EUS-BD group (20 % vs. 4 %, P = 0.01). However, the majority (90 %) of AEs were mild/moderate. Length of stay was significantly longer in the EUS-BD group (6.6 d vs. 2.4 d, P < 0.0001). Conclusions: EUS-BD can be performed with a higher degree of clinical efficacy and shorter procedure time than e-ERCP in patients with surgically-altered upper gastrointestinal anatomy. Whether or not this approach should be first-line therapy in this patient population is highly dependent on the indication for the procedure, the patient’s anatomy, and local practice and expertise.

Analysis of the factors involved in procedural failure: Endoscopic retrograde cholangiopancreatography using a short‐type single‐balloon enteroscope for patients with surgically altered gastrointestinal anatomy

“…As such, adverse events associated with EUS‐BD procedures remain important problems to be resolved. For example, a comparison of outcomes for enteroscopy‐assisted ERCP and EUS‐BD biliary tract treatments in patients with surgically altered gastrointestinal anatomy reported that the higher success rate for EUS‐BD (98% vs 65.3%) was associated with a significantly greater rate of adverse events (20% vs 4%) . Our results show that ERCP‐related procedures using a short SBE provided favorable outcomes with regard to the procedural success rate and the rate of adverse events.…”

Piercing technique via cholangioscopy for the reconstruction of complete anastomotic obstruction after choledochojejunostomy

“…2c,d) (Video S1). Although most CJs are treatable by BE‐ERCP or EUS‐guided procedure, 2–5 some cases require other approaches. To avoid invasive surgery, the piercing technique for cases of complete obstruction of CJs and the percutaneous route for taking the correct direction are useful.…”

Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018

“…On the other hand, a systematic review of BE‐ERCP in patients with surgically altered anatomy showed an adverse event rate of 3.4%. Therefore, BE‐ERCP is clearly a less invasive and safer procedure than PTCD or EUS‐BD . Furthermore, as BE‐ERCP enables treatment of the causes of cholangitis such as bile duct stone or anastomotic stricture at a single session, it appears that BE‐ERCP is useful if the procedure is technically successful.…”