Prospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. May 16, 2018; 10(5): 99-108
Published online May 16, 2018. doi: 10.4253/wjge.v10.i5.99
Different options of endosonography-guided biliary drainage after endoscopic retrograde cholangio-pancreatography failure
José Celso Ardengh, César Vivian Lopes, Rafael Kemp, José Sebastião dos Santos
José Celso Ardengh, Rafael Kemp, José Sebastião dos Santos, Division of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo 14049-900, Brazil
César Vivian Lopes, Department of Gastroenterology and Digestive Endoscopy, Santa Casa Hospital, Porto Alegre 91410-000, Brazil
Author contributions: Ardengh JC performed the procedures; Lopes CV designed the study and wrote the manuscript; Kemp R and dos Santos JS provided the collection of all human material.
Institutional review board statement: The institutional review board statement was approved by protocol No. 2.191.319.
Informed consent statement: All study participants, or their legal guardians, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: César Vivian Lopes, MD, PhD, Doctor, Department of Gastroenterology and Digestive Endoscopy, Santa Casa Hospital, Rua Prof. Cristiano Fischer 668/1001, Porto Alegre 91410-000, Brazil.
Telephone: +55-51-33388054
Received: January 9, 2018
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
Research background

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.

Research motivation

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.

Research objectives

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.

Research methods

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).

Research results

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.

Research conclusions

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.

Research perspectives

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.