Original article
Clinical endoscopy
Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video)

https://doi.org/10.1016/j.gie.2013.01.042Get rights and content

Background

EUS-guided biliary drainage (EUS-BD) was introduced as an effective alternative to percutaneous transhepatic biliary drainage after failed ERCP. However, EUS-BD is technically challenging. The intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure. Therefore, technical advances in guidewire manipulation may be required for EUS-BD.

Objective

To evaluate our treatment algorithm for guidewire manipulation protocol for EUS-BD after failed ERCP.

Design

Prospective, observational cohort study.

Setting

A tertiary-care academic center.

Patients

Forty-five consecutive patients undergoing EUS-BD failed ERCP.

Interventions

Enhanced guidewire manipulation protocol (with a plane parallel to the long axis of the bile duct with an EUS needle tip or a new 0.025-inch guidewire in an extrahepatic approach and intrahepatic bile duct puncture of segment 2 and 4F cannula with guidewire probing in the intrahepatic approach) for rendezvous and antegrade therapy, EUS-BD with transluminal stenting for duodenal invasion, and crossover to another technique if each technique failed.

Main Outcome Measurements

Technical and functional success rates and adverse event rate of the current treatment algorithm for EUS-BD.

Results

The overall technical and functional success rates of EUS-BD in this study were 91% (intention to treat, n = 41/45) and 95% (per protocol, n = 39/41), respectively. Specifically, rendezvous (n = 20) and antegrade therapy (n = 14) were initially feasible in 34 of 45 patients (76%). With our protocol, 25 of 45 patients (56%) were eventually treated with rendezvous and antegrade therapy as a first-line or crossover treatment. EUS-guided biliary drainage with transluminal stenting in patients with duodenal invasion or failed antegrade therapy was feasible in the remaining 20 patients (44%). The overall adverse event rate of EUS-BD was 11%.

Limitations

Single-operator, nonrandomized study.

Conclusions

In this prospective study, our treatment algorithm with an enhanced guidewire manipulation protocol appeared to be technically feasible and effective. Given the favorable success rate and acceptable adverse event rate, this may be considered the standard treatment algorithm for future randomized trials of EUS-BD and percutaneous transhepatic biliary drainage.

Section snippets

Patients and methods

From September 2011 to June 2012, 1350 ERCPs were performed in a 2600-bed, tertiary-care referral hospital by a single experienced endoscopist (D.H.P.) trained in both EUS and ERCP. During this period, 954 cases required biliary decompression for benign or malignant biliary obstruction. During the study period, 40 patients (4.2%) underwent precutting during ERCP because of difficult biliary cannulation. All of these procedures were successful and achieved biliary cannulation. Of the 954

Results

The baseline characteristics are shown in Table 2. The reason for failed ERCP was ampulla of Vater cancer infiltration (n = 8), in duodenal invasion (n = 11), in surgically altered anatomy (n = 14), periampullary diverticulum (n = 7), and 5 in high-grade hilar stricture (n = 5). The number of cases of surgically altered anatomy in this study was pylorus-preserving pancreaticoduodenectomy (n = 5), Whipple procedures (n = 2), Roux-en-Y anastomosis with hepaticojejunostomy (n = 4), total

Discussion

Research to date on EUS-guided biliary drainage can be classified into EUS-guided rendezvous-based or transluminal stenting–based studies (Table 5).1, 7, 8, 11, 13, 15, 22, 23, 24, 25, 26 After failed ERCP, these procedures may be selected according to the expertise of the endoscopist involved and the feasibility of each technique. Thus, no unified or widely accepted treatment algorithm for EUS-BD was available. Recently, a retrospective study on the EUS-guided antegrade therapy–based protocol

Acknowledgments

The authors are indebted to Steven A. Edmundowicz, MD, FASGE (Washington University School of Medicine) for his helpful comments and critical revision of this manuscript.

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    DISCLOSURE: All authors disclosed no financial relationship relevant to this publication.

    If you would like to chat with an author of this article, you may contact Dr Park at [email protected].

    Drs Park and Jeong contributed equally to this article.

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