Published online May 16, 2018. doi: 10.4253/wjge.v10.i5.99
Peer-review started: January 10, 2018
First decision: January 23, 2018
Revised: February 10, 2018
Accepted: March 14, 2018
Article in press: March 15, 2018
Published online: May 16, 2018
Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach to biliary drainage, and, in the failure of the procedure, percutaneous transhepatic biliary drainage or surgery must be used. However, endosonography can guarantee the least invasive and lowest risk treatment for biliary drainage of these cases. This study presents the results of different techniques for endosonography-guided biliary drainage in case of ERCP failure.
In case of ERCP failure, patients must be submitted to surgery or percutaneous transhepatic biliary drainage at different places in the hospital and with a long delay in treatment, conditions which can increase the morbidity and risks for the patient. Endosonography-guided biliary drainage can be performed immediately after ERCP failure, decreasing the time and risk of definitive treatment of the patient.
The main objectives of the study were to evaluate the success rates of endosonography (EUS)-guided biliary drainage techniques after ERCP failure for the management of biliary obstruction, and to propose a rational approach based on the access to the biliary tree and feasibility to recover the guidewire.
In our experience, an alternative to ERCP failure for biliary drainage was necessary in 24 of 3538 (0.68%) cases. Elderly people with malignant biliary obstruction were the most common candidates for the procedure. The sequential endosonography-guided biliary drainage (EUS-BD) procedures proposed for all patients were transhepatic puncture in order to perform the EUS-guided rendez-vous technique. An anterograde approach was attempted when the capture of the guidewire in the duodenum was not possible. If the anterograde approach failed, EUS-guided Hepatogastrostomy was the next alternative. In case of failure of the intrahepatic puncture, patients were submitted to EUS-guided choledochoduodenostomy (EUS-CD).
Patients were submitted to EUS-guided rendez-vous (7), EUS-guided anterograde stent insertion (5), EUS-guided hepaticogastrostomy (6), and EUS-CD (6). Success rates did not differ among the various EUS-BD technique. Overall, technical and clinical success rates were 83.3% and 75%, respectively. The technical success for each technique was 71.4%, 100%, 83.3%, and 83.3%, respectively (P = 0.81). Complications occurred in 3 (12.5%) patients. All of these cases were managed conservatively, but one patient died after a rescue percutaneous transhepatic biliary drainage. Regarding particular EUS-BD techniques, there is a scarcity of comparative studies, and a consensus about the best technique has not been established.
A rational approach to EUS-guided biliary drainage in case of obstructive biliary disease and ERCP failure should begin with the transhepatic approach, followed by particular EUS-guided biliary drainage techniques based on the patient’s anatomy and feasibility to recover the guidewire in the duodenum.
EUS-guided biliary drainage should be included in the therapeutic arsenal for the management of malignant biliary obstruction in case of ERCP failure, and should be the choice rather than surgery or percutaneous transhepatic biliary drainage.