ERCP failure: EUS gallbladder drainage as first alternative?

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is gaining popularity as an option for drainage of the gallbladder in patients suffering from acute cholecystitis who are at high risk for cholecystectomy [1]. The procedure could also be used to convert permanent cholecystostomy to internal drainage [2]. EUS-GBD has been shown by multiple retrospective studies to be associated with reduced adverse events (AEs), reinterventions and readmissions [3 – 5]. The advent of a cautery-tipped lumen-apposing stent also significantly reduced the complexity of the procedure and allowed for creation of a secure anastomosis [6 – 7]. In this issue of Endoscopy International Open, Chang et al presented a series of nine patients who received EUS-GBD as a method of drainage in malignant biliary obstruction with failed ERCP [8]. They reported a clinical success rate of 77.78 %. One patient suffered from recurrent obstruction at 7 months after EUS-GBD and received EUS-guided choledochoduodenostomy.

Performance of EUS-GBD in the setting of malignant biliary obstruction (MBO) is similar to the principle of surgical cholecystojejunostomy. In the 1980 s and 1990 s, there was extensive debate in the surgical literature about whether cholecystojejunostomy or hepaticojejunostomy provided better palliation of MBO. There are several concerns about using the gallbladder as a conduit for biliary drainage. First, effectiveness of the biliary drainage depends on the patency of the cystic duct. In a retrospective study assessing incidence of patent cystic ducts on cholangiograms performed by endoscopic retrograde cholangiopancreatography (ERCP) in patients with MBO, only 50 % of patients had a patent hepatocystic junction [9]. Furthermore, two-thirds of the remaining patients had obstructions less than 1 cm from the hepatocystic junction, potentially increasing risk of future cystic duct obstruction. Results from multiple surgical series demonstrated that the overall rate of recurrent biliary obstruction was between 8 % and 48 % [10 – 12]. Thus, proximity of the cystic duct opening to the site of obstruction may be a risk factor for recurrent obstruction.

EUS-guided biliary drainage (EUS-BD) can be achieved by a number of approaches, either transpapillary or transmurally [13 – 14]. For transpapillary approaches, EUS-rendezvous ERCP or antegrade stenting could be performed. For transmural procedures, EUS-guided choledochoduodenostomy (CDS) and hepaticogastrostomy (HGS) could be performed. Performance of these procedures during the learning curve can be associated with a risk of AEs. Performance of them by an endoscopist fluent in them is associated with procedural AE rates comparable to that of ERCP. The availability of single-step devices for CDS and hepaticogastrostomy will further improve the ease and safety of performing these procedures [15 – 16]. The benefit of transmural drainage is that the stent is placed in the bile duct far from the tumor, thus risk of tumor in-growth is significantly reduced. Indeed, a recent randomized study demonstrated that EUS-BD may provide higher stent patency rates and lower AE rates (particularly for pancreatitis) as compared to ERCP in unresectable MBO [16].

Hence, in the presence of available expertise and devices, EUS-BD should still be the first choice for draining MBO. In the event that EUS-BD cannot be performed, EUS-GBD can then potentially provide another option for biliary drainage.

Competing interests

Prof. Anthony Y.B. Teoh is a consultant for Boston Scientific, Cook, Taewoong, and Microtech Medical Corporations.

• References

• 1 Mori Y, Itoi T, Baron TH. et al. Tokyo Guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018; 25: 87-95
• 2 Law R, Grimm IS, Stavas JM. et al. Conversion of percutaneous cholecystostomy to internal transmural gallbladder drainage using an endoscopic ultrasound-guided, lumen-apposing metal stent. Clin Gastroenterol Hepatol 2016; 14: 476-480
• 3 Teoh AY, Serna C, Penas I. et al. Endoscopic ultrasound-guided gallbladder drainage reduces adverse events compared with percutaneous cholecystostomy in patients who are unfit for cholecystectomy. Endoscopy 2017; 49: 130-138
• 4 Tyberg A, Saumoy M, Sequeiros EV. et al. EUS-guided versus percutaneous gallbladder drainage: isnʼt it time to convert?. J Clin Gastroenterol 2016; 52: 79-84
• 5 Irani S, Ngamruengphong S, Teoh A. et al. Similar efficacies of endoscopic ultrasound gallbladder drainage with a lumen-apposing metal stent versus percutaneous transhepatic gallbladder drainage for acute cholecystitis. Clin Gastroenterol Hepatol 2017; 15: 738-745
• 6 Teoh AY, Binmoeller KF, Lau JY. Single-step EUS-guided puncture and delivery of a lumen-apposing stent for gallbladder drainage using a novel cautery-tipped stent delivery system. Gastrointest Endosc 2014; 80: 1171
• 7 Teoh AY, Chiu PW, Hon SF. et al. Ex vivo comparative study using the Endolifter(R) as a traction device for enhancing submucosal visualization during endoscopic submucosal dissection. Surg Endosc 2013; 27: 1422-1427
• 8 Chang AI, Dong E, Kwok KK. Endoscopic ultrasound-guided transmural gallbladder drainage in malignant obstruction using a novel lumen-apposing stent – a case series (with video). Endosc Int Open 2018; 07: E655-E661
• 9 Tarnasky PR, England RE, Lail LM. et al. Cystic duct patency in malignant obstructive jaundice. An ERCP-based study relevant to the role of laparoscopic cholecystojejunostomy. Ann Surg 1995; 221: 265-271
• 10 Eastman MC, Kune GA. The objectives of palliative surgery in pancreas cancer: a retrospective study of 73 cases. Aust N Z J Surg 1980; 50: 462-464
• 11 Watanapa P, Williamson RC. Surgical palliation for pancreatic cancer: developments during the past two decades. Br J Surg 1992; 79: 8-20
• 12 Gough IR, Mumme G. Biliary and duodenal bypass for carcinoma of the head of the pancreas. J Surg Oncol 1984; 26: 282-284
• 13 Teoh AYB, Dhir V, Kida M. et al. Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 2018; 67: 1209-1228
• 14 Dhir V, Isayama H, Itoi T. et al. EUS-guided biliary and pancreatic duct interventions. Dig Endosc 2017; 29: 472-485
• 15 Tsuchiya T, Teoh AYB, Itoi T. et al. Long-term outcomes of EUS-guided choledochoduodenostomy using a lumen-apposing metal stent for malignant distal biliary obstruction: a prospective multicenter study. Gastrointest Endosc 2018; 87: 1138-1146
• 16 Paik WH, Lee TH, Park DH. et al. EUS-guided biliary drainage versus ercp for the primary palliation of malignant biliary obstruction: a multicenter randomized clinical trial. Am J Gastroenterol 2018; 113: 987-997