Interventional EUS cholangiography: a report of five cases

doi:10.1016/S0016-5107(04)01528-7

Gastrointestinal Endoscopy

Volume 60, Issue 1, July 2004, Pages 138-142

https://doi.org/10.1016/S0016-5107(04)01528-7 Get rights and content

Abstract

Background

ERCP may be unsuccessful because of the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic cholangiography is a classic technique for accessing the bile duct and remains the primary alternative when biliary ERCP is unsuccessful. With the evolution of interventional EUS, additional options are available for management of biliary obstruction.

Methods

EUS cholangiography was performed, after which the puncture was enlarged to form an enterocholedochal fistula that was used for interventions that resulted in biliary decompression in 5 patients with obstructive jaundice.

Observations

Cholangiography was readily performed in all 5 patients. In one patient, a guidewire could not be manipulated across the papilla via the enterocholedochal fistula, necessitating percutaneous intervention. Biliary decompression was achieved in the other 4 patients, in the last two, as a single procedure.

Conclusions

Interventional EUS cholangiography is a new technique that allows drainage of a dilated biliary system when the bile duct is inaccessible by conventional ERCP.

Section snippets

Patients and methods

Five consecutive patients with obstructive jaundice in whom conventional ERCP was unsuccessful underwent interventional EUS-guided cholangiography (IEUC) with the intent of ductal decompression (Table 1). Our institutional review board waived formal review and approval of the procedures because they were considered extensions of existing procedures.

A standard echoendoscope (GF-UCT140; Olympus America Corp., Melville, N.Y.) was used for all interventions. The extrahepatic bile duct was measured

Observations

All patients were hospitalized for observation after IEUC; jaundice resolved in all cases (Table 2). Patient 3 developed ascites and fever, and paracentesis revealed serosanguinous bile-stained fluid. A percutaneous 7F pigtail catheter was placed in the pelvic fluid collection under US guidance. ERCP was repeated, and injection of contrast through the gastrocholedochal stent did not demonstrate a leak. The peritonitis resolved within 3 weeks, and the percutaneous catheter was removed. There was

Discussion

EUS has impacted interventional endoscopy in many ways. With this modality, detailed imaging can be obtained because of the close proximity of the high-frequency transducer to the region of interest.¹⁴ The ability to place a needle in the EUS field has increased diagnostic and therapeutic capability, including FNA,12., 13. celiac plexus neurolysis,7., 15. drainage of cystic lesions,11., 16. and pancreaticogastrostomy.¹⁷ The distal biliary and pancreatic ducts are readily identified when an

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The role of endoscopic ultrasound (EUS) has transitioned from a diagnostic to a therapeutic one over the past 40 years. With the advent of curvilinear array echoendoscopes in the 1990s with an accessory channel, multiple tools and devices have been developed and used for a variety of transluminal interventions. EUS provides a viable option and is becoming the procedure of choice for many interventions, including bile and pancreatic duct drainage, guiding angiotherapy, pancreatic fluid collection management, gallbladder drainage, and creating a gastrojejunostomy. Although reports demonstrate the technical success of these interventions, there is tremendous study heterogeneity and a relative lack of controlled randomized trials, which may limit our understanding of their role and utility. Furthermore, adverse events are relatively common and occasionally severe. Despite the limitations, available data strongly indicate the efficacy of EUS interventions when performed by well-trained endosonographers in carefully selected patients and managed in a multidisciplinary setting.
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It may be appropriately used after failed ERCP attributable to periampullary diverticula, tortuous bile ducts, impacted stones, or malignancy with bile-duct infiltration. Transpapillary drainage via EUS-BD can be attempted using classic rendezvous, parallel rendezvous,9 or standard cannulation, without rendezvous, after cholangiography by contrast injection through an EUS needle.10,11 In this procedure, under EUS and Doppler guidance a needle is inserted into either the left hepatic or common bile duct.
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EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown.
To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist.
Multicenter retrospective study.
Public health system hospitals with experience in ESCP in Spain.
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Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed.
A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula.
Retrospective study.
Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.

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Case StudiesInterventional EUS cholangiography: a report of five cases

Abstract

Background

Methods

Observations

Conclusions

Section snippets

Patients and methods

Observations

Discussion

Gastrointest Endosc

Am J Surg

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Case Studies
Interventional EUS cholangiography: a report of five cases