Figure - available from: Journal of Gastrointestinal Cancer
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EUS-guided hepaticogastrostomy (HGS). a An intrahepatic bile duct was punctured under EUS guidance. b After confirmation of successful puncture, a guidewire was inserted. c After dilation of the puncture tract with a bougie dilator, a weave-type partially covered metal stent (Niti-S, Century Medical) was deployed. d Sufficient length of the proximal part of the stent was located in the stomach
Source publication
Purpose:
To evaluate clinical outcomes of endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) for unresectable malignant biliary obstruction for cases in which endoscopic retrograde cholangiopancreatography (ERCP) failed at a high-volume center.
Methods:
All 99 EUS-BD cases of unresectable malignant biliary obstruction at Sendai City Me...
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Background
If the guidewire becomes kinked by the needle, guidewire manipulation may be difficult, and can cause complications such as guidewire shearing or injury during endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS). To overcome this matter, we have previously described a technical tip for preventing guidewire injury, termed ‘liver...
Currently, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is widely performed worldwide for various benign and malignant biliary diseases in cases of difficult or unsuccessful endoscopic transpapillary cholangiopancreatography (ERCP). Furthermore, its applicability as primary drainage has also been reported. Although recent advances in...
of event: Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) with the placement of a fully covered self-expandable metal stent (SEMS) is an alternative method to percutaneous transhepatic biliary drainage in cases of failed endoscopic retrograde cholangiopancreatog-raphy (ERCP) for malignant distal biliary obstruction. We report the case...
Background and aim
Endoscopic ultrasound-guided biliary drainage is an alternative to failed endoscopic retrograde cholangiopancreatography. Unfortunately, this procedure remains relatively less explored in Egypt due to its high cost, lack of adequate training, and the perception of increased risk. This study is the first multicenter Egyptian exper...
Feasibility of endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage is not always applicable due to anatomical alterations or to inability to access the papilla. Percutaneous transhepatic biliary drainage has always been considered the only alternative for this indication. However, endoscopic ultrasonography-guided biliary dra...
Citations
... If promptly recognized, misdeployment can generally be managed by intraprocedural stent-in-stenting [12,63]. Other rarely reported adverse events are hemobilia, cholecystitis, arteriobiliary fistula and pseudoaneurysm, with mortality rates from 0-3% [64]. A meta-analysis reported a pooled adverse events rate of 14% for EUS-CDS (4% cholangitis, 4% bleeding, 4% bile leak, 3% perforation) [65]. ...
Malignant biliary obstruction (MBO), both distal and hilar, represents an ensemble of different clinical conditions frequently encountered in everyday practice. Given the frequent unresectability of the disease at presentation and the increasing indications for neoadjuvant chemotherapy, endoscopic biliary drainage is generally required during the course of the disease. With the widespread use of interventional endoscopic ultrasound (EUS) and the introduction of dedicated devices, EUS-guided biliary drainage has rapidly gained acceptance, together with transpapillary endoscopic biliary drainage and the percutaneous approach. This comprehensive review describes the current role of endoscopy for distal and hilar MBO supported by evidence, with a focus on the current hot topics in this field.
... This condition may manifest as signs of peritoneal irritation, accompanied by the identification of newly developed ascites or localized fluid collection through imaging modalities such as CT scans. 18 Stent patency was defined as the interval from the index procedure of EUS-BD to the first stent dysfunction with recurrent obstructive symptoms and signs accompanied by biliary obstruction and dilatation of the bile duct on imaging modalities. 5 Patients who died without stent dysfunction were considered censored. ...
Background
Endoscopic ultrasound-guided biliary drainage (EUS-BD), classified as choledochoduodenostomy (CDS) and hepaticogastrostomy (HGS), is a feasible and effective alternative for distal malignant biliary obstruction (MBO) in failed endoscopic retrograde cholangiopancreatography. However, the preferred technique for better outcomes has not yet been evaluated.
Objectives
We compared the long-term outcomes between the techniques.
Design
Retrospective comparative study.
Methods
We reviewed consecutive patients who underwent EUS-CDS or EUS-HGS with transmural stent placement for distal MBO between 2009 and 2022. The primary outcome was the stent patency. The secondary outcomes were technical and clinical success, adverse events (AEs) of each technique, and independent risk factors for stent dysfunction.
Results
In all, 115 patients were divided into EUS-CDS (n = 56) and EUS-HGS (n = 59) groups. Among them, technical success was achieved in 98.2% of EUS-CDS and 96.6% of EUS-HGS groups. Furthermore, clinical success was 96.4% in EUS-CDS and 88.1% in EUS-HGS groups, without significant difference (p = 0.200). The mean duration of stent patency for EUS-CDS was 770.3 days while that for EUS-HGS was 164.9 days (p = 0.010). In addition, the only independent risk factor for stent dysfunction was systematic treatment after EUS-BD [hazard ratio and 95% confidence interval 0.238 (0.066–0.863), p = 0.029]. The incidence of stent dysfunction of EUS-HGS was higher than EUS-CDS (35.1% versus 18.2%, 0.071), despite no significant differences even in late AEs.
Conclusion
In distal MBO, EUS-CDS may be better than EUS-HGS with longer stent patency and fewer AEs. Furthermore, systematic treatment after EUS-BD is recommended for the improvement of stent patency.
... 4 This percentage is lower than the clinical success rates reported in other studies. Kanno et al. 5 reported a technical success rate of 98% and a clinical success rate of 93% in patients with unresectable malignant biliary obstruction who underwent EUS-BD. Paik et al. 6 also reported a technical success rate of 93.8% and a clinical success rate of 90% in a similar patient population. ...
Background/aims:
Endoscopic ultrasound (EUS) has become an essential diagnostic and therapeutic tool. EUS was introduced in 2013 in Indonesia and is considered relatively new. This study aimed to describe the current role of interventional EUS at our hospital as a part of the Indonesian tertiary health center experience.
Methods:
This retrospective study included all patients who underwent interventional EUS (n=94) at our center between January 2015 and December 2020. Patient characteristics, technical success, clinical success, and adverse events associated with each type of interventional EUS procedure were evaluated.
Results:
Altogether, 94 interventional EUS procedures were performed at our center between 2015 and 2020 including 75 cases of EUS-guided biliary drainage (EUS-BD), 14 cases of EUS-guided pancreatic fluid drainage, and five cases of EUS-guided celiac plexus neurolysis. The technical and clinical success rates of EUS-BD were 98.6% and 52%, respectively. The technical success rate was 100% for both EUS-guided pancreatic fluid drainage and EUS-guided celiac plexus neurolysis. The adverse event rates were 10.6% and 7.1% for EUS-BD and EUS-guided pancreatic fluid drainage, respectively.
Conclusions:
EUS is an effective and safe tool for the treatment of gastrointestinal and biliary diseases. It has a low rate of adverse events, even in developing countries.
... [13] Kanno et al. reported that TRBO of MS did not differ from that of PS (MS, 339 days; PS, 125 days; P = 0.61). [20] These similar results of RBO between MS and PS may reflect the small sample size of the study. In a retrospective analysis of risk factors for AEs in EUS-CDS, Matsumoto et al. reported that MSs exhibited longer stent patency than PSs (MS: 329 days; PS: 89 days; P < 0.001). ...
Background and objectives:
In transpapillary biliary drainage, metal stents (MSs) exhibit a lower incidence of a biliary obstruction than plastic stents (PSs). However, few studies have compared recurrent biliary obstruction (RBO) when MSs and PSs are used in EUS-guided hepaticogastrostomy (EUS-HGS) and choledochoduodenostomy (EUS-CDS). We retrospectively evaluated the RBO for both stents in each procedure.
Patients and methods:
: Between November 2012 and December 2020, 85 and 53 patients who underwent EUS-HGS and EUS-CDS for unresectable malignant biliary obstruction, respectively, were enrolled. Factors associated with RBO were assessed. Clinical outcomes were compared between the MS and PS groups using propensity score matching.
Results:
: The clinical success rate and procedure-related adverse events were similar in the MS and PS groups. Multivariate analysis identified the use of PS as a factor associated with RBO (EUS-HGS, P = 0.03; EUS-CDS, P = 0.02). After matching, the median time to RBO in EUS-HGS (MS: 313; PS: 125 days; P = 0.01) in the MS group was longer than that in the PS group. The cumulative incidence of RBO at 1, 3, and 6 months in the MS group was significantly lower than that in the PS group for EUS-HGS (MS: 4.0%, 8.2%, and 8.2%; PS: 12.4%, 24.9%, and 39.5%, respectively, P = 0.01).
Conclusions:
: MS exhibited a lower rate of RBO than PS for EUS-HGS and EUS-CDS.
... 17 Kanno et al reported acute cholecystitis in 4% of 99 patients who underwent EUS-BD. 18 Acute cholecystitis, especially early cholecystitis seen within days of stent insertion, occurs due to occlusion of the cystic duct orifice by the covered stents used during EUS-CDS. Isayama et al studied the occurrence of acute cholecystitis after placement of transpapillary biliary stent in malignant biliary obstruction and reported that involvement of the cystic duct orifice by the tumor was an important risk factor for the development of postprocedure cholecystitis. ...
Endoscopic ultrasound-guided biliary drainage ( EUS-BD) has a potential risk of clinically significant adverse events including fatal complications. Learning from complications improves the results from interventional procedures especially the high-risk procedure like EUS-BD. The various complications that have been reported following EUS-BD include bile leak, bleeding, cholangitis, peritonitis, stent migration both internal and external as well as in the peritoneal cavity and fatal perforations. In this technical review, we discuss technical strategies to prevent serious adverse events during EUS-BD using a case based approach.
... Abdominal pain occurred commonly (up to 18 %) but was usually mild [33]. Also rarely reported were pneumoperitoneum, hemobilia, cholecystitis, arteriobiliary fistula, pseudoaneurysm, and inadvertent portal vein puncture [30,35,93,94,96,97]. Mortality ranged from 0 % to 3 % [96]. ...
... Also rarely reported were pneumoperitoneum, hemobilia, cholecystitis, arteriobiliary fistula, pseudoaneurysm, and inadvertent portal vein puncture [30,35,93,94,96,97]. Mortality ranged from 0 % to 3 % [96]. Poincloux et al. reported a high mortality of 6 %; however, the mortality rate was lower in the second 50 cases compared with the first (decreasing from 10 % to 2 %), suggesting a learning curve effect [30]. ...
... Poincloux et al. reported a high mortality of 6 %; however, the mortality rate was lower in the second 50 cases compared with the first (decreasing from 10 % to 2 %), suggesting a learning curve effect [30]. The most common long-term AE is stent occlusion, with the median time of occurrence ranging from 5 to 12 months [30,93,96]. This can often be resolved during a second procedure, either by stent-in-stent placement or drainage of alternative segments [33,93]. ...
Main Recommendations
1 ESGE recommends a prolonged course of a prophylactic broad-spectrum antibiotic in patients with ascites who are undergoing therapeutic endoscopic ultrasound (EUS) procedures.Strong recommendation, low quality evidence.
2 ESGE recommends placement of partially or fully covered self-expandable metal stents during EUS-guided hepaticogastrostomy for biliary drainage in malignant disease.Strong recommendation, moderate quality evidence.
3 ESGE recommends EUS-guided pancreatic duct (PD) drainage should only be performed in high volume expert centers, owing to the complexity of this technique and the high risk of adverse events.Strong recommendation, low quality evidence.
4 ESGE recommends a stepwise approach to EUS-guided PD drainage in patients with favorable anatomy, starting with rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP), followed by antegrade or transmural drainage only when RV-ERP fails or is not feasible.Strong recommendation, low quality evidence.
5 ESGE suggests performing transduodenal EUS-guided gallbladder drainage with a lumen-apposing metal stent (LAMS), rather than using the transgastric route, as this may reduce the risk of stent dysfunction.Weak recommendation, low quality evidence.
6 ESGE recommends using saline instillation for small-bowel distension during EUS-guided gastroenterostomy.Strong recommendation, low quality evidence.
7 ESGE recommends the use of saline instillation with a 19G needle and an electrocautery-enhanced LAMS for EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) procedures.Strong recommendation, low quality evidence.
8 ESGE recommends the use of either 15- or 20-mm LAMSs for EDGE, with a preference for 20-mm LAMSs when considering a same-session ERCP.Strong recommendation, low quality evidence.
... Abdominal pain occurred commonly (up to 18 %) but was usually mild [33]. Also rarely reported were pneumoperitoneum, hemobilia, cholecystitis, arteriobiliary fistula, pseudoaneurysm, and inadvertent portal vein puncture [30,35,93,94,96,97]. Mortality ranged from 0 % to 3 % [96]. ...
... Also rarely reported were pneumoperitoneum, hemobilia, cholecystitis, arteriobiliary fistula, pseudoaneurysm, and inadvertent portal vein puncture [30,35,93,94,96,97]. Mortality ranged from 0 % to 3 % [96]. Poincloux et al. reported a high mortality of 6 %; however, the mortality rate was lower in the second 50 cases compared with the first (decreasing from 10 % to 2 %), suggesting a learning curve effect [30]. ...
... Poincloux et al. reported a high mortality of 6 %; however, the mortality rate was lower in the second 50 cases compared with the first (decreasing from 10 % to 2 %), suggesting a learning curve effect [30]. The most common long-term AE is stent occlusion, with the median time of occurrence ranging from 5 to 12 months [30,93,96]. This can often be resolved during a second procedure, either by stent-in-stent placement or drainage of alternative segments [33,93]. ...
Main Recommendations
1 ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.
Strong recommendation, moderate quality evidence.
2 ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.
Weak recommendation, moderate quality evidence.
3 ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.
Strong recommendation, low quality evidence.
4 ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.
Strong recommendation, low quality evidence.
5 ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.
Strong recommendation, high quality of evidence.
6 ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.
Strong recommendation, low quality evidence.
7 ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates.
Strong recommendation, low quality evidence.
8 ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.
Weak recommendation, low quality evidence.
... Several types of stents were used in the studies included plastic stent, partially covered SEMS, and FCSEMS. 15,17,40 We performed a subgroup analysis of the studies that used FCSEMS. Results showed that EUS-CDS and EUS-HGS have similar success rates. ...
... This differs from the results of a study by Hedjoudje et al 11 This may be related to the number of studies included, the nature of the studies, and the definition of adverse events. One drawback of EUS-BD is bile leakage, which could lead to bile peritonitis; sometimes, it is fatal 17,49 The incidence of bile leakage was 2.68% and 3.17% in the in the EUS-CDS and EUS-HGS groups, respectively. No bile leakage was observed in patients who underwent EUS-CDS with FCSEMS. ...
Objectives:
This study aimed to estimate the safety and efficacy of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for malignant biliary obstruction.
Methods:
We conducted a literature search using PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Studies that compared EUS-CDS and EUS-HGS were included in this study.
Results:
Thirteen studies were eligible for inclusion. The technical [odds ratio (OR): 0.95; 95% confidence interval (CI): 0.51-1.74) and clinical (OR: 1.13; 95%CI: 0.66-1.94) success rates of EUS-CDS were comparable to those of EUS-HGS. However, EUS-CDS had less reintervention (OR: 0.31; 95%CI: 0.16-0.63) and stent obstruction (OR: 0.48; 95%CI: 0.21-0.94) than EUS-HGS. Both groups had similar adverse events (OR: 1.00; 95%CI: 0.70-1.43) and overall survival (hazard ratio: 1.07; 95%CI: 0.58-1.97).
Conclusions:
EUS-CDS and EUS-HGS have comparable technical and clinical success rates, adverse events, and overall survival. However, EUS-CDS has less reintervention and stent obstruction.
... In this study involving 10 referral centers, EUS-BD for unresectable MBO with SAA patients was technically and clinically successful in 100% and 95% of enrolled patients, respectively. Previous large-scale studies reported the efficacy of EUS-BD for MBO; 5,9,13,[16][17][18][19][20][21][22][23][24][25] however, these studies included a limited number of patients bearing SAA (Table 3). Compared with these studies, this study aimed to determine the efficacy of EUS-BD specifically for SAA patients. ...
Background
Endoscopic treatment for malignant biliary obstruction (MBO) in patients bearing surgically altered anatomy (SAA) is not well-established. Although endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a new treatment option for MBO, limited data are available regarding the efficacy and safety of EUS-BD in patients with SAA. We conducted a multicenter prospective registration study to evaluate the efficacy and safety of EUS-BD in this population.
Methods
This study involved 10 referral centers in Japan. Patients with SAA who were scheduled to receive EUS-BD for unresectable MBO between May 2016 and September 2018 were prospectively registered. The primary endpoint was technical success and the secondary outcomes were clinical success, procedure time, procedure-related adverse events (AEs), stent patency, and overall survival.
Results
In total, 40 patients were prospectively enrolled. The surgical reconstruction methods were gastrectomy with Roux-en-Y reconstruction (47.5%), gastrectomy with Billroth-II reconstruction (15%), pancreaticoduodenectomy (27.5%), and hepaticojejunostomy with Roux-en-Y reconstruction (10%). EUS-BD was performed for primary biliary drainage in 31 patients and for rescue biliary drainage in nine patients. Transmural stenting alone (60%), antegrade stenting alone (5%), and a combination of the two techniques (35%) were selected for patients treated with EUS-BD. Technical and clinical success rates were 100% (95% confidence interval, 91.2–100.0%) and 95% (95% confidence interval, 83.1–99.4%), respectively. Mean procedure time was 36.5 min. Early AEs were noted in six patients (15%): three self-limited bile leak, one bile peritonitis, and two pneumoperitonea. Late AEs occurred in six patients (15%): one jejunal ulcer and five stent occlusions. Stent patency rate after 3 months of survival was 95.7% (22/23). Median overall survival was 96 days.
Conclusion
EUS-BD for MBO in patients with SAA appears to be effective and safe not only as a rescue drainage technique after failed endoscopic retrograde cholangiography but also as a primary drainage technique.
Clinical Trial Registration
UMIN000022101
Background and Aims
Multiple meta-analyses have evaluated the technical and clinical success of Endoscopic ultrasound (EUS)-guided biliary drainage (BD), but those concerning adverse events (AE) are limited. The present meta-analysis was aimed to analyze the AEs associated with various types of EUS-BD.
Methods
A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes included incidence of overall AE, major AE, procedure-related mortality, and reintervention. The event rates were pooled using a random effects model.
Results
A total of 155 studies (n = 7887) were included in the final analysis. The pooled clinical success rate and incidence of AE with EUS-BD were 95% (95%CI: 94.1 – 95.9) and 13.7% (95%CI: 12.3 – 15.0), respectively. Among the early AEs, bile leak was the commonest AE followed by cholangitis with a pooled incidence of 2.2% (95%CI: 1.8 – 2.7), and 1.0% (95%CI: 0.8 – 1.3), respectively. The pooled incidence of major AE and procedure-related mortality with EUS-BD were 0.6% (95%CI: 0.3 – 0.9) and 0.1% (95%CI: 0.0 – 0.4), respectively. The pooled incidence of delayed migration and stent occlusion were 1.7% (95%CI: 1.1 – 2.3), and 11.0% (95%CI: 9.3 – 12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95%CI: 14.0 – 18.3; I2 = 77.5%).
Conclusion
Despite a high clinical success, EUS-BD may be associated with AE in one-seventh of the cases. However, major AE and mortality incidence remains less than 1%, which is reassuring.
