The role of endoscopic ultrasound guidance for biliary and pancreatic duct access and drainage to overcome the limitations of ERCP: a retrospective evaluation

Abstract

Background EUS-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed ERCP is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure. Methods Consecutive duct access procedures (n=2205; 95% biliary) performed between June 2013-November 2015 at a tertiary-care center were reviewed. ERCP was used first-line, EUS-DAD as salvage of ERCP, and PTBD when both failed. Procedures were defined as index in patients without prior endoscopic duct access and combined when EUS-DAD followed successful ERCP. The main outcomes were EUS-DAD and PTBD rates. Results EUS-DAD was performed overall in 7.7% (170/2205), 9.1% (116/1274) index and 5.8% (54/931) follow-up procedures. Most index EUS-DADs were performed following (46%) or anticipating (39%) ERCP failure, whereas 15% followed successful ERCP (combined procedures). Among index procedures, the EUS-DAD rate was higher in surgically-altered anatomy (58.2% [39/67)] vs. 6.4% [77/1207]). PTBD was required in 0.2% (3/1274). Among follow-up procedures, ERCP represented 85.7%, cholangio-pancreatography through mature transmural fistulas 8.5% and EUS-DAD 5.8%. No patient required PTBD. The secondary PTBD rate was 0.1% (3/2205). Six primary PTBDs were performed (0.4% [9/2211] overall PTBD rate). Conclusions EUS-DAD was required in 7.7% of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1%. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes ERCP limitations precluding primary and salvage PTBD in most cases.

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

“…The aim of EUS-guided PD drainage is to relieve the ductal hypertension that is responsible for pain or recurrent acute pancreatitis in patients with a dilated MPD. The primary indication for EUS-guided PD drainage is an inaccessible papilla or failed papillary cannulation of the PD [104,106,111,[114][115][116]. This frequently arises in patients with symptomatic chronic pancreatitis with a tight ductal stricture, disconnected PD, or pancreaticojejunostomy anastomotic stricture following pancreaticoduodenectomy.…”

EUS and ERCP in the Same Session for Biliary Stones: From Risk Stratification to Treatment Strategy in Different Clinical Conditions

“…Other limitations with ERCP can be encountered when cannulation fails due to periampullary diverticulum or post-surgical anatomical changes. Garcia–Alonso et al reported 170 cases of salvage EUS-guided ductal access and drainage ERCP failures [ 28 ]. In approximately half of the cases, EUS-guided drainage procedures were performed anticipating rather than following ERCP failures (e.g., post-surgical anatomy).…”

Endoscopic ultrasound-guided ductal access and drainage – thus far and much further

“…EUS-DAD for the bile duct was required in 7.7 % of cases (170/ 2205) and for the pancreatic duct in 10 % of cases (10/104). The highly favorable results of the study show that ERCP enhanced by EUS-DAD brings complex pancreaticobiliary duct disease within the reach of endoscopic therapy, thereby negating the need for percutaneous drainage in the management of the vast majority of patients [9]. There are some limitations to the study, namely its retrospective nature, the heterogeneity of practice patterns and diagnoses, and the lack of adverse event information and other relevant intraprocedural data.…”

“…The article by Garcia-Alonso et al represents a real-world practical analysis of their experience in using the EUS-guided techniques and how these techniques complement traditional ERCP [9]. This single-center study followed a large number of ERCPs performed in a tertiary referral academic institution.…”