Published online Mar 7, 2020. doi: 10.3748/wjg.v26.i9.947
Peer-review started: December 6, 2019
First decision: January 12, 2020
Revised: February 13, 2020
Accepted: February 21, 2020
Article in press: February 21, 2020
Published online: March 7, 2020
Although several techniques for endoscopic ultrasound-guided biliary drainage (EUS-BD) are available at present, an optimal treatment algorithm of EUS-BD has not yet been established.
To evaluate the clinical utility of treatment method conversion during single endoscopic sessions for difficult cases in initially planned EUS-BD.
This was a single-center retrospective analysis using a prospectively accumulated database. Patients with biliary obstruction undergoing EUS-BD between May 2008 and April 2016 were included. The primary outcome was to evaluate the improvement in EUS-BD success rates by converting the treatment methods during a single endoscopic session. Secondary outcomes were clarification of the factors leading to the conversion from the initial EUS-BD and the assessment of efficacy and safety of the conversion as judged by technical success, clinical success, and adverse events (AEs).
A total of 208 patients underwent EUS-BD during the study period. For 18.8% (39/208) of the patients, the treatment methods were converted to another EUS-BD technique from the initial plan. Biliary obstruction was caused by pancreatobiliary malignancies, other malignant lesions, biliary stones, and other benign lesions in 22, 11, 4, and 2 patients, respectively. The reasons for the difficulty with the initial EUS-BD were classified into the following 3 procedures: Target puncture (n = 13), guidewire manipulation (n = 18), and puncture tract dilation (n = 8). Technical success was achieved in 97.4% (38/39) of the cases and clinical success was achieved in 89.5% of patients (34/38). AEs occurred in 10.3% of patients, including bile leakage (n = 2), bleeding (n = 1), and cholecystitis (n = 1). The puncture target and drainage technique were altered in subsequent EUS-BD procedures in 25 and 14 patients, respectively. The final technical success rate with 95%CI for all 208 cases was 97.1% (95%CI: 93.8%-98.9%), while that of the initially planned EUS-BD was 78.8% (95%CI: 72.6%-84.2%).
Among multi-step procedures in EUS-BD, guidewire manipulation appeared to be the most technically challenging. When initially planned EUS-BD is technically difficult, treatment method conversion in a single endoscopic session may result in successful EUS-BD without leading to severe AEs.
Core tip: Treatment methods were converted from an initially planned endoscopic ultrasound-guided biliary drainage (EUS-BD) technique in a single endoscopic session in cases with difficulties. In 18.8% cases, treatment methods were converted to another EUS-BD technique. The technical and clinical success rates were 97.4% and 89.5%, respectively. Mild adverse events occurred in 10.5%. Final technical success rate of all 208 cases was 97.1%-much higher than that of the initially planned EUS-BD. When the initially planned EUS-BD was technically difficult, treatment method conversion during the single endoscopic session was likely to contribute to improvements in the technical success of EUS-BD, without leading to serious AEs.