EUS-guided intrahepatic biliary drainage: a large retrospective series and subgroup comparison between percutaneous drainage in hilar stenoses or postsurgical anatomy

Abstract

Background and study aims Endoscopic ultrasound-guided intrahepatic biliary drainage (EUS-IBD) struggles to find a place in management algorithms, especially compared to percutaneous drainage (PTBD). In the setting of hilar stenoses or postsurgical anatomy data are even more limited. Patients and methods All consecutive EUS-IBDs performed in our tertiary referral center between 2012 – 2019 were retrospectively evaluated. Rendez-vous (RVs), antegrade stenting (AS) and hepatico-gastrostomies (HGs) were compared. The predefined subgroup of EUS-IBD patients with proximal stenosis/surgically-altered anatomy was matched 1:1 with PTBD performed for the same indications. Efficacy, safety and events during follow-up were compared. Results One hundred four EUS-IBDs were included (malignancies = 87.7 %). These consisted of 16 RVs, 43 ASs and 45 HGs. Technical and clinical success rates were 89.4 % and 96.2 %, respectively. Any-degree, severe and fatal adverse events (AEs) occurred in 23.3 %, 2.9 %, and 0.9 % respectively. Benign indications were more common among RVs while proximal stenoses, surgically-altered anatomy, and disconnected left ductal system among HGs. Procedures were shorter with HGs performed with specifically designed stents (25 vs. 48 minutes, P = 0.004) and there was also a trend toward less dysfunction with those stents (6.7 % vs. 30 %, P = 0.09) compared with previous approaches. Among patients with proximal stenosis/surgically-altered anatomy, EUS-IBD vs. PTBD showed higher rates of clinical success (97.4 % vs. 79.5 %, P = 0.01), reduced post-procedural pain (17.8 % vs. 44.4 %, p = 0.004), shorter median hospital stay (7.5 vs 11.5 days, P = 0.01), lower rates of stent dysfunction (15.8 % vs. 42.9 %, P = 0.01), and the mean number of reinterventions was lower (0.4 vs. 2.8, P < 0.0001). Conclusions EUS-IBD has high technical and clinical success with an acceptable safety profile. HGs show comparable outcomes, which are likely to further improve with dedicated tools. For proximal strictures and surgically-altered anatomy, EUS-IBD seems superior to PTBD.

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…In malignant distal biliary obstruction, all options including EUS-RV procedures, EUS-CDS, EUS-HGS, EUS-guided antegrade stent placement, and EUS-GBD may be considered, whilst in malignant hilar obstruction only EUS-guided antegrade stent placement and EUS-HGS are feasible alternatives. EUS-HGS can be complementary to ERCP in patients with an unresectable hilar stricture and inadequate drainage of the left hepatic duct [23,33,66,67]. Similarly, EUS-guided hepaticoduodenostomy may aid in drainage of the right biliary system [68,69].…”

Double EUS bypass: same sequence, different reasons

“…Recently, we assessed the use of EUS-guided biliary drainage in the context of failed ERCP and postsurgical anatomy. 4 This series included 9 patients in whom a double EUS bypass was performed. Analysis of these procedures revealed that in 6 of 9 combined procedures, significant contrast extravasation or free air surrounding the stomach was seen after successful intrahepatic biliary drainage, 4 which may compromise visualization during EUS-GJ.…”

“… 4 This series included 9 patients in whom a double EUS bypass was performed. Analysis of these procedures revealed that in 6 of 9 combined procedures, significant contrast extravasation or free air surrounding the stomach was seen after successful intrahepatic biliary drainage, 4 which may compromise visualization during EUS-GJ. Furthermore, in situations where biliary drainage has been performed first, additional insufflation of CO 2 during EUS endoscope insertion or while placing a nasojejunal catheter in preparation for EUS-GJ will keep the transgastric tract patent.…”

Learning in therapeutic EUS

“…The development of linear sectorial array EUS scopes in the early 1990 brought a new approach to the diagnostic and therapeutic dimensions of EUS capabilities, opening the possibility to perform puncture over a direct ultrasonographic guidance. Therapeutic EUS (TEUS) encompasses different procedures such as EUS-guided biliary drainage,[ 1 2 ] drainage of pancreatic fluid collections,[ 3 4 ] pancreatic duct drainage,[ 5 ] gallbladder drainage,[ 6 ] EUS-guided gastroenterostomy,[ 7 8 ] EUS-guided pancreatic tumor ablation. [ 9 ]…”