TEMPORARY EUS-GUIDED ANASTOMOSES (TEA) AS THERAPEUTIC ACCESS FISTULAS (TAF) IN BENIGN BILIARY OBSTRUCTION (BBO) NOT AMENABLE TO ERCP: EMERGING APPLICATION OF EUS-GUIDED BILIARY DRAINAGE (EUS-BD)

Aims:

Transpapillary EUS-BD is gaining acceptance in BBO. The potential of transmural EUS-BD in complex BBO warrants study. To assess feasibility and efficacy of TEA using transmural covered self-expandable metal-stents (cSEMS) to provide interval biliary drainage and create TAF for biliary endotherapy under cholangioscopy/fluoroscopy in BBO not amenable to ERCP.

Methods:

402 EUS-BD among 12,355 consecutive ERCPs databased at single Unit over 12-years were queried for: BBO + Transmural cSEMS placement ± removal. Lack of dilation precluded EUSBD attempts in 14/108 BBO. Transmural EUS-BD succeeded in 91/94 (96.8%). 9 BBO with plastic stents TEAs and 8 subsequently proved malignant were excluded. 87 patients (40.7% female; 71.5 [IQR 62.5 – 79.5] years old) were reviewed for indications, technique, interventions, technical success, AEs and final therapeutic success.

Results:

Indications: strictures (40.7%), CBD stones (23.3%), transections (19.1%), hepatholithiasis (15.1%). SAA in 59.5% (Roux-en-Y 33.7%, Whipple 12.3%, Bariatric 6%). ERCP attempted in 93.2%, with failed access/cannulation in 61.3% and incomplete/impossible therapy in 38.5%. In 93% TEA, 10 × 60 mm cSEMS with anchoring flaps and/or additional clips/coaxial pigtails were used. TEA were predominantly transhepatic (78.7%). Over a median (IQR) cSEMS indwell time of 81.5 (21 – 188) days a median (IQR) of 3 (2 – 4) treatment sessions guided by antegrade cholangiography/cholangioscopy through the cSEMS and/or through the naked TAF were performed for antegrade balloon-dilation, stent insertion/removal, stone removal ± lithotripsy, rendezvous, magnetic compression anastomoses, needle-knife incision. cSEMS removal was successful in all 79.2% in whom attempted (20.8% treatment drop-outs or follow-up losses). Final clinical success achieved in 77.4% of patients with cSEMS removed. 26.3% experienced AEs (7.8% severe).

Conclusions:

Select BBO patients (refractory stones/strictures ± SAA) not amenable to ERCP can be treated using TEA as TAF for serial endotherapy. This shift from percutaneous to transmural endoscopy replicates prior experience in malignancy. Surgery and PTBD can be avoided in 80%.