COMBINED RETROGRADE/ANTEGRADE ENDOSCOPIC APPROACH TO DISCONNECTED BILE-DUCT (DBD) AS A RESULT OF SEVERE POSTOPERATIVE INJURY

Aims:

DBD is defined at ERCP by lack of proximal filling under pressure cholangiography with/without contrast extravasation. Combined percutaneous-endoscopic approaches are encouraging. We hypothesized that aggressive retrograde (ERCP) and/or antegrade (EUS) attempts at recanalization might salvage DBD for endotherapy. To assess feasibility and efficacy of an endoscopic treatment algorithm of DBD and characterize the heterogeneous techniques used.

Methods:

Among 756 databased ERCPs at single center 2010 – 2018 for postoperative complications (strictures/leaks) in 261 patients (169 Liver transplant [LT]; 92 Other), 51 (20 female; age = 62.5 [34 – 92] years) had DBD (24 post-cholecystectomy, 15 post-LT, 12 Other). Procedural success/complications, technique and outcomes were determined.

Results:

Recanalization was achieved in 32/51 DBD, by means of ERCP in 16 (8 post-LT, 4 post-cholecystectomy); ERCP combined with EUS-guided antegrade approach in 15 (5 post-LT, 6 post-cholecystectomy), and EUS alone in 1. Lack of upstream dilation precluded EUS in 13, and recanalization failed in 6 despite EUS-hepatico-gastrostomy. 12 initial failures underwent surgical repair. 21/32 recanalizations required forced antegrade/retrograde techniques: hard end of stiff guidewire, intraductal needle-knife/hollow-needle puncture, transhepatic peritoneoscopy or magnetic-compression anastomosis. Recanalization took a mean (range) of 3.4 (1 – 6) ERCPs. Coincidental bilomas were endoscopically drained in 4 DBD. 26 Patients completed 31 treatment courses of stenting (2 plastic & 22 covered metal with/without plastic) after 269 (51 – 698) days of stents in place. After a mean follow-up of 479 (30 – 2200) days post-stent removal, 8 recurrences developed (5 successfully re-treated endoscopically, 2 undergoing stenting, 1 surgery). Overall complications: 7 (2 severe) post-procedural or stent related cholangitis, 4 post-sphincterotomy/EUS-BD bleeding, 2 pancreatitis, one death.

Conclusions:

62.7% of DBDs can successfully be recanalized endoscopically by means of forced mechanical (guidewires, needles), thermal or magnetic techniques. Antegrade EUS approaches can salvage 50% ERCP failures. Mid-term treatment outcomes using this algorithm for DBDs appear comparable to those seen with partial postoperative strictures.