Aims:
Failed cannulation occurs in 3% of ERCPs. EUS-RV can overcome failure. We aimed to
identify predictors of success and rescue options of EUS-RV.
Methods:
Review of prospective database on 6843 consecutive ERCPs between 2010 – 2017. Inclusion:
patients with biliary obstruction and failed cannulation undergoing EUS-RV.
Results:
79 consecutive EUS-RV (57% male, median age 76.5, 69.5% benign). Procedural variables
shown in Table-1. Primary technical success was 63.3% (3.5% failed biliary puncture,
65.5% failed guidewire placement, 31% failed cannulation). Variables associated with
technical success in univariate analysis were flexible RV (antegrade passage of the
guidewire through a catheter across papilla/stricture) versus rigid RV (through needle)
(89.9% vs. 56.7% p = 0,01), transgastric versus transduodenal access (94.1 vs. 54.8%,
p = 0.003), intrahepatic versus extrahepatic access (83,3 vs. 57,4%, p = 0,05), and
benign stricture (25%, versus remainder indications 67.6%, p = 0,02). In multivariate
analysis, transgastric access and indication other than benign stricture remained
significant. In 75.9% (22/29) of failed EUS-RV, rescue biliary drainage was achieved
during the same session (40% transmural-EUS, 32% methylene-blue cholangiography, and
12% re-ERCP), final technical success rate of 91%. 68 EUS-RV patients had one-month
follow-up available; 6 complications occurred in 5 procedures (8.8%): bleeding 2,
perforation 2, acute pancreatitis 1, biliary leakage 1; 3 of them were severe, requiring
surgery (1 death).
Tab. 1
|
Access
|
- Transgastric, (21,5%)
- Transduodenal, (78,5%)
|
|
Target
|
- Intrahepatic-bile-duct, (22,8%)
- Extrahepatic-bile-duct, (77,2%)
|
|
Target dilation
|
- Present, (70,3%)
- Absent, (29,7%)
|
|
Cannulation
|
- Parallel, (46.2%)
- Over-the-wire, (53,8%)
|
|
RV rigid/flexible
|
- Rigid, (76,9%)
- Flexible, (23,1%)
|
Conclusions:
Primary success rates of EUS-RV remain low. Flexible catheters to direct antegrade
passage of the guidewire could improve them. 75% of failed EUS-RV can be rescued in
the same session either by transmural-EUS or reattempted ERCP following methylene-blue/contrast
EUS-cholangiography, resulting in 91% final technical success rates.
