EUS-GUIDED GALLBLADDER DRAINAGE AS A RESCUE TECHNIQUE AFTER FAILED ERCP

Aims Papilla cannulation is not always achieved during ERCP procedure. When this happens EUS-guided Access is the choice. However, sometimes this is not posible and in these cases gallbladder drainage may be an alternative.

To evaluate EUS-guided galbladder drainage in patients with obstructive jaundice in which ERCP fails.

Methods Retrospective case series. EUS-guided galbladder drainage performed as a rescue technique for biliary drainage after failed ERCP were included.

The correct placement of the stent in the gallbladder was considered technical success, and the reduction of >50% in bilirubin levels after 14 days clinical success. In all cases, 10x10mm Hot-Axios stents with FreeHand technique were used. In 8 cases, coaxial pigtail was placed.

Results Ten patients were included (7 male). Mean age was 71±12.7 years.

The indication was neoplastic jaundice (n=9) and benign obstruction secondary to choledocholithiasis (n=1).

Cholecystogastrostomy was performed in 6 patients and cholecystoduodenostomy in the remaining four. Technical success was achieved in 100% and clinical success in 80%. There were no intraprocedural or early adverse events, however 4 late complications (40%) were observed: 3 stent obstruction and one self-limited gallbladder haemorrhage. All complications appeared in patients with cholecystogastrostomy and were solved by therapeutical endoscopy. 20% of patients without clinical succes required a second endoscopy. Clinical failures were due to recurrence of jaundice before 14 days, requiring hepaticogastrostomy and confirmation of cystic obstruction after galbladder drainage, and a new successful rendezvous attempt was made. The mean duration of the procedure was 12.7±5.8 minutes. The median time to bilirubin normalization was 13 days (range 9-23). The median duration of follow-up: 41.5 (17-165) days.

Conclusions EUS-guided galbladder drainage is an effective alternative after ERCP failure when other biliary drainage techniques are not possible and cystic duct is permeable. The duodenal route is preferable and coaxial pigtail placement is recommended.