Indications of EUS-BD

Technique of EUS-BD

EUS-Rv

EUS-Rv is usually performed when there is failed ERC due to a difficult papilla or malignant distal bile duct obstruction. The authors prefer to perform the procedure for benign conditions. The concept of EUS-Rv is similar to percutaneous rendezvous ERCP, but the procedure is performed under EUS guidance. It is a type of access procedure aimed at passage of the guidewire through the papilla to complete an ERC (Fig. 28.2). The bile duct can be punctured from the first or second part of the duodenum or from the stomach by a 19G needle. A guidewire is then passed through the papilla for retrieval by a duodenoscope. The retrieved wire is then used to guide bile duct cannulation, and the procedure is completed with ERC.

EUS-AG

EUS-AG is usually performed in the presence of an inaccessible papilla/anastomosis and a dilated intrahepatic duct. In EUS-AG, the aim is to place a stent in an antegrade manner across a stricture distal to the puncture site (Fig. 28.3 and Video 28.1). The left intrahepatic duct is first punctured by a 19G needle, followed by insertion of a guidewire. The guidewire is then manipulated across the stricture. The track is dilated with electrocautery. A covered or uncovered stent is then inserted in an antegrade manner and placed across the stricture.

EUS-CDS

EUS-CDS is usually performed when ERC fails due to a malignant distal common bile duct obstruction and when the first part of the duodenum is available for drainage. In EUS-CDS and –HGS, a neofistula is first created followed by placement of stent. In EUS-CDS, the common bile duct is punctured with a 19G needle from the first part of the duodenum (Fig. 28.4). A guidewire is inserted through the needle and passed deeply into the biliary system. The track is then dilated with electrocautery and a 4 mm balloon. This is followed by insertion of a partially or fully covered biliary metal stent.

EUS-HGS

EUS-HGS can be performed when ERC fails due to a malignant bile duct obstruction, but the papilla is inaccessible or if the first of the duodenum is infiltrated by tumor (Fig. 28.5). The left intrahepatic duct is punctured with a 19G needle from the stomach. A guidewire is inserted through the needle deeply into the biliary system. The track is then dilated with electrocautery, and a partially or fully covered metallic stent is inserted bridging the left intrahepatic to the stomach.

Choice of the Technique

The advantages and disadvantages of each type of EUS-BD procedure are different, and applicability is dependent on the underlying anatomy of the patient. In some patients, multiple techniques may be feasible and the choice depends on outcomes of the procedures, the underlying etiology, the availability of devices, and expertise.

As mentioned previously, EUS-Rv is mainly an access procedure and usually does not involve fistula dilation. The risk of the procedure is related to a prior difficult ERC and the additional risks from EUS-guided bile duct puncture are minimal. However, there are a number of obstacles to the procedure. Firstly, the difficulty of the procedure is related to guidewire manipulation across any existing stricture and through the papilla, and the reported success rate is 65–80% [39]. Thereafter, the echoendoscope needs to be exchanged with a duodenoscope for guidewire retrieval. The process is sometimes difficult, and there may be inadvertent displacement of the guidewire back into the bile duct during the process.

Similarly, the main difficulty of EUS-AG is manipulation of the guidewire across any stricture after bile duct puncture. The procedure also requires a dilated intrahepatic duct for puncture. In theory, there is a risk of bile leak from the puncture site, but if this occurs, it tends to be mild and self-limiting. The technique is suitable in patients where the papilla is inaccessible. However, if recurrent obstruction of the stent occurs, reintervention through the stent may not be possible and another EUS-BD procedure may be required.

EUS-CDS and –HGS are transmural EUS-BD techniques that require creation of a neofistula and creation of an anastomosis with placement of a stent. The potential advantages are that the procedures do not have risk of pancreatitis and the stents seldom suffer from tumor ingrowth as they are placed far away from the tumor. However, the integrity of the anastomosis is dependent on the properties of the stents placed and EUS-specific stents that encompass antimigratory properties are preferred [40]. In the event of stent misdeployment or migration, outcomes may be catastrophic. Potential adverse events from transmural procedures are higher and include pneumoperitoneum, bleeding, cholangitis, stent dislocation, free perforation, bile leak, and bile peritonitis. Rarer adverse events include hemobilia, acute cholecystitis, duodenal double puncture, mediastinitis, and mortality.

Outcomes of the EUS-BD Procedures

EUS-BD Versus ERCP

Recently, three randomized studies have compared EUS-BD with ERC and metallic stenting (SEMS) as a primary means of obtaining biliary drainage in patients with malignant biliary obstruction (Table 28.3). The principle is that in EUS-BD, a stent is placed at a site that is away from the tumor. Thus, the chances of tumor ingrowth or overgrowth could be reduced and stent patency can be improved. Other potential benefits of EUS-BD over ERC include reduced procedural times and no risk of pancreatitis. However, this needs to be balanced against the need for dedicated expertise and devices, increased risks of bile leak, and stent migration. In two small randomized studies comparing EUS-CDS with ERC and SEMS, there were no differences in technical and clinical success rates, adverse events, and reinterventions [47, 48]. In the other study, EUS-CDS and -HGS using a dedicated device was compared with ERC with SEMS in unresectable malignant distal biliary obstruction [49]. The technical success rate of EUS-BD was not inferior to ERC with SEMS (93.8% vs 90.2%, P = 0.003), and clinical success rates were similar (90% vs 94.5%, P = 0.49). There were lower adverse events rates (6.3% vs. 19.7%, P = 0.03) and reintervention (15.6% vs. 42.6%) in the EUS-BD arm. Postprocedural pancreatitis was lower in the EUS-BD arm (0 vs. 14.8%, P = 0.001). A higher stent patency rate at 6 months (85.1% vs. 48.9%, P = 0.001) and longer mean patency time (208 days vs. 165 days) was also observed in EUS-BD.

Table 28.3

Studies comparing EUS-BD with ERC and metallic stenting for primary biliary drainage

Author	Design	Year	Patients N	Type of procedure	Technical success (%)	Clinical success (%)	30-day adverse events (%)	Stent patency at 6 months (%)	Reintervention (%)
Park [47]	RCT	2018	14 14	EUS-CDS ERC	93 100	100 93	31a 31	69a 69	–
Bang [48]	RCT	2018	34 33	EUS-CDS ERC	90.9 94.1	97 91.2	14.7 6.1	–	3 2.9
Paik [49]	RCT	2018	64 61	EUS-CDS or HGS ERC	93.8 90.2	90.4 94.5	6.3 19.7	85.1 48.9	15.6 42.6

RCT randomized controlled trial

^aOnly the overall number of patients with adverse events and stent dysfunction was provided in this study

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related posts:

and Competency in Endoscopic Resection Myotomy for Zenker’s Diverticulum (Z-POEM) ESD Tools and Accessories for ESD ESD Mucosal Resection of the Esophagus

Stay updated, free articles. Join our Telegram channel

Join