A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction

Background and study Aims: Selective biliary cannulation is unsuccessful in 5 % to 10 % of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard, but endoscopic ultrasound guided rendezvous (EUSr) have been increasingly used for biliary decompression in this patient population. Our aim was to compare the initial success rate, long-term efficacy, and safety of PBD and EUSr in relieving MDBO after failed ERC

Patients and methods: A retrospective study involving 50 consecutive patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008 – 2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002 – 2008). Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates after biliary decompression.

Results: The mean age at presentation was 66.5 (± 12.6 years), 28 patients (54.9 %) were female. The etiology of MDBO was pancreaticobiliary malignancy in 44 (88 %) and metastatic disease in 6 (12 %) cases. Biliary drainage was technically successful by EUSr in 19 (76 %) cases and by PBD in 25 (100 %) (P = 0.002). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (P = 0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (P = 0.001).

Conclusions: Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful, patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions.

Meeting presentations: Annual Digestive Diseases Week 2015

• References

• 1 Sarkaria S, Lee HS, Gaidhane M et al. Advances in endoscopic ultrasound-guided biliary drainage: a comprehensive review. Gut Liver 2013; 7: 129-136
• 2 Khashab MA, Valeshabad AK, Afghani E et al. A comparative evaluation of EUS-guided biliary drainage and percutaneous Drainage in patients with distal malignant biliary obstruction and failed ERC. Dig Dis Sci 2015; 60: 557-565
• 3 Iwashita T, Lee JG, Shinovia S et al. Endoscopic ultrasound-guided rendezvous for biliary access after failed cannulation. Endoscopy 2012; 44: 60-65
• 4 Artifon EL, Aparicio D, Paione JB et al. Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage. J Clin Gastroenterol 2012; 46: 768-774
• 5 Hara K, Yamao K, Mizuno N et al. Endoscopic ultrasound-guided choledochoduodenostomy. Dig Endosc 2010; 22: 147-150
• 6 Iwashita T, Doi S, Yasuda I. Endoscopic ultrasound-guided biliary drainage: a review. Clin J Gastroenterol 2014; 7: 94-102
• 7 Covey AM, Brown KT. Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol 2008; 11: 14-20
• 8 Giovannini M, Moutardier V, Pesenti C et al. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy 2001; 33: 898-900
• 9 Gupta K, Mallery S, Hunter D et al. Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERC. Rev Gastroenterol Disord 2007; 7: 22-37
• 10 Khashab MA, Dewitt J. EUS-guided biliary drainage: is it ready for prime time?. Yes! Gastrointest Endosc 2013; 78: 102-105
• 11 Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases. Gastrointest Endosc 2004; 59: 100-107
• 12 Iwashita T, Lee JG. Endoscopic ultrasonography-guided biliary drainage: rendezvous technique. Gastrointest Endosc Clin N Am 2012; 22: 249-258
• 13 Liu YD, Wang ZQ, Wang XD et al. Stent implantation through rendezvous technique of PTBD and ERCP: the treatment of obstructive jaundice. J Dig Dis 2007; 8: 198-202
• 14 Barkay O, Sherman S, McHenry L et al. Therapeutic EUS-assisted endoscopic retrograde pancreatography after failed pancreatic duct cannulation at ERC. Gastrointest Endosc 2010; 71: 1166-1173
• 15 Park do H, Jeong SU et al. Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video). Gastrointest Endosc 2013; 78: 91-101
• 16 Itoi T, Binmoeller K, Itowkawa F et al. Endoscopic ultrasonography-guided cholecystogastrostomy using a lumen-apposing metal stent as an alternative to extrahepatic bile duct drainage in pancreatic cancer with duodenal invasion. Dig Endosc 2013; 25 (Suppl. 02) 137-141
• 17 Boulay BR, Gardner TB, Gordon SR. Occlusion rate and complications of plastic biliary stent placement in patients undergoing neoadjuvant chemoradiotherapy for pancreatic cancer with malignant biliary obstruction. J Clin Gastroenterol 2010; 44: 452-455
• 18 Sut M, Kennedy R, McNamee J et al. Long-term results of percutaneous transhepatic cholangiographic drainage for palliation of malignant biliary obstruction. J Palliat Med 2010; 13: 1311-1313
• 19 Itoi T, Binmoeller KF, Shah J et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012; 75: 870-876
• 20 Itoi T, Itokawa F, Uraoka T et al. Novel EUS-guided gastrojejunostomy technique using a new double-balloon enteric tube and lumen-apposing metal stent (with videos). Gastrointest Endosc 2013; 78: 934-939