Background and study aims: Endoscopic retrograde cholangiopancreatography (ERCP)-guided implantation of a biliary endoprosthesis or stent is the gold standard treatment for biliary obstructions. When the papilla cannot be traversed because there is pyloric or duodenal stenosis, or the catheter cannot be introduced, or because of previous gastrointestinal surgery (Billroth II gastric resection, Whipple procedure, gastrectomy with Roux-en-Y reconstruction), the alternative treatment is considered to be percutaneous transhepatic cholangiography and drainage (PTCD). The aim of the study was to investigate the further alternative of endoscopic ultrasound (EUS)-guided transgastric or transjejunal biliary drainage where PTCD failed or was declined, and particularly, the feasibility and outcome of this option.
Patients and methods: Over 3 years all appropriate consecutive patients (as defined above) were enrolled in this prospective, observational, single-center, case series study, and patient and intervention data were recorded. Feasibility was characterized by success rate (regression of cholestasis), and outcomes by complication rate, mortality, and follow-up findings.
Results: Between November 2002 and December 2005, eight patients (in 10 interventions) underwent this new biliary drainage procedure. The routes were transesophageal (n = 1), transgastric (n = 4), and transjejunal (n = 3, including a rendezvous technique with ERCP [n = 1]). The indications were cholestasis, arising from recurrent tumor growth (n = 5, 62.5 %), that included gastric carcinoma after previous gastrectomy (n = 4) and a periampullary carcinoma after previous Whipple procedure (n = 1); arising from Klatskin tumor (n = 2, 25 %); and from benign stenosis of a hepaticojejunostomy (n = 1, 12.5 %). Five patients (62.5 %) received a metal stent, and three (37.5 %) had a plastic prosthesis (8.5-Fr double-pigtail). The technical success rate was 90 % (9/10) and the clinical success rate was 88.9 % (8/9). There was only one case of cholangitis (12.5 %) and slight postinterventional pain, but no severe complications such as bleeding or perforation, and no mortality. During follow-up (range 4 weeks to 3 years) re-interventions were needed in two patients (20 %) because of increasing cholestasis; these resulted in technical success and clinical improvement.
Conclusion: EUS-guided transgastric or transjejunal biliary drainage is a reasonable, feasible and encouraging treatment option in selected patients as indicated, with a low peri-interventional risk. It broadens the therapeutic spectrum but still needs further evaluation and follow-up investigation.
References
-
1
Byrne M F, Gerke H, Mitchell R M. et al .
Yield of endoscopic ultrasound-guided fine-needle aspiration of bile duct lesions.
Endoscopy.
2004;
36
715-719
-
2
Giovannini M, Moutardier V, Pesenti C. et al .
Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.
Endoscopy..
2001;
33
898-900
-
3
Giovannini M, Dotti M, Bories E. et al .
Hepaticogastrostomy by echo endoscopy as a palliative treatment in a patient with metastatic biliary obstruction.
Endoscopy.
2003;
35
1076-1078
-
4
Kahaleh M, Yoshida C, Yeaton P.
EUS antegrade pancreatography with gastropancreatic duct stent placement. Review of two cases.
Gastrointest Endosc.
2003;
6
919-923
-
5
Kahaleh M, Wang P, Shami V M. et al .
EUS-guided transhepatic cholangiography: report of 6 cases.
Gastrointest Endosc.
2005;
61
307-313
-
6
Mallery S, Matlock J, Freeman M L.
EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases.
Gastrointest Endosc.
2004;
59
100-107
-
7
Seifert H, Wehrmann T, Hilgers R. et al .
Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities.
Gastrointest Endosc.
2004;
60
61-67
U. Will, MD
Department of Internal Medicine III
Municipal Hospital
Strasse des Friedens 122
07548 Gera
Germany
Fax: +49-365-8282402
Email: uwe.will@wkg.srh.de
