EUS-Guided Bilio-Pancreatic Drainage



Fig. 34.1
6F cystostome (Endoflex Company)



Dilators are required to enlarge the fistula tract following puncture. Bougie (6-7F) or balloon (4–6 mm) dilators such as the Soehendra biliary dilation catheter (Cook Medical) or Hurricane biliary balloon dilatation catheter (Boston Scientific) may be used. To minimize pneumoperitoneum following EUS-guided biliary drainage , CO2 should be used for insufflation during all these procedures. [26] Prophylactic antibiotics should also be administered to all patients.




What Is the Technique of EUS-Guided Biliary Access?


There are a variety of ways to access the biliary system and establish drainage. No single approach appears superior based on current studies, [26] and the decision to choose a particular approach is individualized to the patient. The extrahepatic or intrahepatic bile duct can be punctured and a stent can be deployed in the usual retrograde fashion during a rendezvous, antegrade across the gastrointestinal wall and down the stricture, or through the gastrointestinal wall to create a bilio-enteric fistula. With the extrahepatic approach, usually the duodenal bulb is punctured, although, rarely the antrum is traversed. With the intrahepatic approach, the left intrahepatic ducts are accessed through the gastric fundus about 2–3 cm below the cardia along the lesser curvature and rarely through the distal esophagus or jejunum in postsurgical anatomy.


EUS-Guided Rendezvous (Fig. 34.2)




A308307_1_En_34_Fig2_HTML.jpg


Fig. 34.2
Rendezvous technique using EUS guidance: Left panel shows EUS-FNA using 19G needle to puncture dilated left intrahepatic bile duct followed by bile aspiration and then contrast injection. Right panel shows long guidewire advanced antegrade down through the distal biliary stricture and coiling out in the duodenum

This figure illustrates the EUS-guided rendezvous technique . If the papilla is accessible, this is the preferred approach. Either an intrahepatic or extrahepatic puncture can be performed to access the bile duct. Some experts prefer the intrahepatic approach as it is thought to cause less bile leak than the extrahepatic approach. [24] In the intrahepatic approach, the therapeutic linear echoendoscope is positioned in the stomach along the mid-lesser curvature, and after puncturing the left hepatic biliary system using a 19G needle, bile is aspirated and contrast injected. Then a long 0.035 in. hydrophilic guidewire (Tracer Metro Direct, Cook Endoscopy or Jagwire, Boston Scientific, Paris, France) is inserted into the bile duct and looped inside the duodenum. Advancing the guidewire through the needle and down the intrahepatic ducts through the stricture and out the ampulla is often the most difficult part of the procedure. Because of the long distance the wire needs to travel with this intrahepatic approach; pushability and transmission of torque are often limited in advancing it through a tight stricture.

On the other hand, the extrahepatic approach has its own issues. Puncturing through the duodenal bulb for an extrahepatic approach may be challenging due to the long position of the echoendoscope making maneuvering a 19G needle difficult, and from this position, the wire will have a tendency to head towards the hilum rather than the ampulla. In order to advance the wire out the ampulla, a short scope position is preferred. Before puncturing the bile duct, the position of the needle can be checked with fluoroscopy. Then the needle is withdrawn and the echoendoscope with the needle are gently withdrawn leaving the guidewire in place. Afterwards, a duodenoscope is advanced to the second/third portion of the duodenum, parallel to the guidewire in the duodenum. Cannulation can be attempted alongside the guidewire, or the guidewire is captured with a standard snare or forceps and pulled out through the working channel of the duodenoscope. An ERCP cannula is advanced over the guidewire, and the ERCP can be completed in usual retrograde fashion.

The rendezvous technique, although attractive because it preserves the normal anatomy without creating a new fistulous communication between the biliary tree and gastrointestinal lumen, is potentially fraught with difficulties at several steps. If the intrahepatic approach is used, advancing the guidewire, the long distance through the papilla can be arduous. With the extrahepatic approach, several punctures into the bile duct may be necessary before being able to direct the guidewire out the papilla. Similarly, once the guidewire has been looped in the duodenum, exchanging the echoendoscope for the duodenoscope can be cumbersome. If the rendezvous approach fails or is not possible due to duodenal obstruction, EUS-guided bilioenteric anastomoses may be attempted.


EUS-Guided Bilioenteric Anastomoses



Choledochoduodenostomy (CD) (Video 34.1)


The formation of permanent bilioenteric fistulae whether a choledochoduodenostomy or hepaticogastrostomy should be reserved in patients with unresectable malignancies. In choledochoduodenostomy, a 19 G needle is inserted transduodenally into the bile duct under EUS guidance. Bile is aspirated and contrast is injected into the bile duct for cholangiography. A 450-cm long, 0.035-in. guidewire is inserted through the 19 G needle into the bile duct. With the echoendoscope in a long position in the proximal duodenum, advancing the wire towards the hilum usually allows an easier angle to advance the stent. Only after the wire position is secured should dilation be performed to decrease risk of bile leakage. The choledochoduodenal fistula is dilated using a 6–to 7F biliary bougie dilator (Soehendra biliary dilator; Cook Medical), 4–6 mm balloon dilator, or a 6Fr cystostome (Endoflex, Germany). Overdilation should be avoided to decrease the risk of bile leakage. A 7F–10F biliary plastic stent or a covered self-expandable metallic stent (SEMS) is placed through the choledochoduodenostomy site into the extrahepatic bile duct. Uncovered metal stents should not be used to create bilioenteric fistulae due to the potential risk of bile leakage and peritonitis.


Left Hepaticogastrostomy (HGE) (Fig. 34.3)




A308307_1_En_34_Fig3_HTML.jpg


Fig. 34.3
Hepaticogastrostomy performed after ERCP failed to drain the left hepatic lobe in patient with a Klatskin Tumor. Top panels show two overlapping metal biliary stents in right main hepatic duct with EUS-FNA using a 19G needle into the left intrahepatic duct showing a mildly dilated left hepatic duct. A long guidewire is advanced antegrade into the duodenum, the tract is dilated using a 6.5 Fr diathermic sheath, and then a fully covered metal stent is inserted. Bottom panels show abdominal CT scan, fluoroscopic, and endoscopic image of metal stent deployed to create hepaticogastrostomy

EUS-guided hepaticogastrostomy was first reported by Burmester et al. [7] in 2003. The technique is basically similar to EUS-guided drainage of pancreatic pseudocysts. By using an interventional echoendoscope, the dilated left hepatic duct (segment III) is well visualized. Hepaticogastrostomy is then performed under combined fluoroscopic and ultrasound guidance, with the tip of the echoendoscope positioned such that the inflated balloon is in the middle part of the lesser curvature of the stomach. A 19G needle (EchoTip® Access Needle, Cook Ireland Ltd., Limerick, Ireland) is inserted transgastrically into the distal part of the left hepatic duct and following aspiration of bile, contrast medium is injected. Opacification demonstrates dilated biliary ducts proximal to the complete obstruction. The needle is exchanged over a guidewire (0.02 in. diameter, Terumo Europe, Leuven, Belgium) for a 6.5F diathermic sheath (prototype Cysto-Gastro set, EndoFlex, Voerde, Germany), which is then used to enlarge the channel between the stomach and the left hepatic duct. The sheath was introduced by using cutting current in this figure. However, electrocautery is usually not necessary and following needle puncture, dilation can be performed using a bougie or balloon dilator. After exchange over a guidewire (TFE-coated 0.035 in. diameter, Cook Europe, Bjaeverskov, Denmark), an 8.5 F by 8 cm long hepatico-gastric stent or a 10 mm by 8 cm long covered SEMS (Boston Scientific) is positioned. As observed by fluoroscopy, contrast is emptied from the stent into the stomach. To prevent bile leakage, a 6 or 7F naso-biliary drain can be left through the metallic stent for aspiration during the ensuing 48 h. More recently we decided to insert a covered stent within an uncovered stent to prevent bile leakage. Hepaticogastrostomy may be combined with placement of an additional metallic stent bridging the distal stricture as described below.


Antegrade Approach


This approach refers to the formation of a temporary bilioenteric fistula followed by management of the stricture in an antegrade fashion. The technique involves access to the left intrahepatic ducts as described above using a 19G FNA needle and a 450 cm long 0.035 in. guidewire advanced through the stricture into the duodenum, similar to during a rendezvous using the intrahepatic approach. This is followed by dilation of the fistula tract using a bougie or balloon dilator, and then placement of a metal stent in an antegrade fashion. The presence of the dilating catheter through which the wire can be manipulated facilitates advancement of the wire, unlike during a rendezvous procedure. Theoretical concern for bile leakage exists if a second stent is not placed bridging the left intrahepatic bile ducts and the stomach although this has not been reported in the literature. Extrahepatic biliary puncture is not recommended in the antegrade approach because advancing the stent is often challenging due to the angle the stent needs to traverse.


Case Continued


EUS-guided biliary drainage was performed using general anesthesia and CO2 insufflation after administering intravenous ciprofloxacin. EUS revealed a 2 cm common bile duct. Because the papilla was accessible, the rendezvous approach was initially chosen. However, despite multiple attempts at positioning the therapeutic linear echoendoscope to allow the guidewire to be advanced out the papilla, this could not be achieved. Therefore, the decision was made to perform a choledochoduodenostomy. With the echoendoscope in the duodenal bulb in the long position, the 19G needle punctured the CBD (Fig. 34.4a), bile was aspirated, and contrast injected. A long 0.035 in. dreamwire guidewire (Boston Scientific) was advanced into the biliary system. The needle was removed and the transmural tract dilated using a Soehendra dilation catheter up to 7Fr (Fig. 34.4b). A 10 mm × 4 cm long fully covered SEMS was deployed with the distal end in the duodenal bulb and good bile drainage (Fig. 34.4c, d).



A308307_1_En_34_Fig4_HTML.jpg


Fig. 34.4
a EUS-guided choledochoduodenostomy with 19G needle punctured into dilated common bile duct. b Contrast injection shows diffusely dilated proximal extrahepatic and intrahepatic bile duct with no contrast exiting the ampulla. Long 0.035 in. dreamwire guidewire (Boston Scientific) is in the bile duct with a 7Fr Soehendra catheter dilator (Cook Medical) advanced across the choledochoduodenostomy site. c Fluoroscopic view of fully covered SEMS deployed to establish the choledochoduodenostomy. d Endoscopic view of fully covered SEMS with distal end in duodenal bulb. (Courtesy Dr. Christopher Thompson, Brigham and Women’s Hospital, Boston, MA)


What Are the Role, Success, and Complications of EUS-Guided Biliary Access


ERCP is the gold standard technique for the drainage of obstructive jaundice due to malignant or benign etiologies. The success rate of biliary stenting by ERCP is around 80–85 % with unsuccessful ERCPs resulting from either failed cannulation of the papilla or inability to reach the papilla due to intestinal obstruction or surgically altered anatomy. Percutaneous biliary drainage is the accepted alternative, but carries a high complication rate from bleeding or peritoneal bile leakage (20–30 %). The morbidity and mortality of surgery as a palliative procedure are 35–50 % and 10–15 %, respectively. Therefore, these new techniques of biliary drainage using EUS guidance could provide another option. A small retrospective study of patients with inaccessible papilla compared 25 patients undergoing EUS-guided biliary drainage using either the antegrade approach or the creation of a bilioenteric fistula to 26 patients having percutaneous biliary drainage. [37] Both clinical access at achieving internal biliary drainage with stents (92 % vs. 46 %, p 0.05) and complications (20 % vs. 46 %, p 0.05) were favorable with the EUS arm. There was a death following the EUS approach and two deaths after percutaneous drainage. Another small retrospective series comparing EUS to percutaneous biliary drainage in failed ERCPs for distal biliary strictures found greater technical success with the percutaneous approach (100% versus 86%, p=0.007) with a trend towards increased adverse events in the percutaneous groups (39% versus 18%, p=0.08). [38] Further rigorous randomized studies are necessary to compare the EUS to the percutaneous approach.

To date, 549 patients with EUS-guided bile duct drainage (EUS-CD = 284; EUS-HGE = 265, and EUS rendezvous = 33) have been reported in 30 studies (Table 34.1). [436] A 19 gauge or 22 gauge fine needle followed by balloon dilatation, needle knife, or cystotome were used to puncture the intrahepatic bile ducts in all these patients. We recently published a large multicenter study including 240 patients in whom ERCP failed due to tumor infiltration at the papilla, duodenal obstruction, inability to advance the guidewire through the stricture, and postsurgical anatomy, and EUS-guided biliary access was employed. [39] Over 80 % of the patients had malignant biliary obstruction. The intrahepatic approach was used in 60 % of patients with 90 % success, which was similar to the 84 % success with the extrahepatic approach. Complications occurred in about 31 % of patients with similar rates for both the intrahepatic and extrahepatic routes as well as for plastic and metal stents, although there was a higher rate of cholangitis with plastic stents (11 % versus 3 %, p = 0.02).




Table 34.1
Summary of the published literature on EUS-guided biliary drainage (HGE, CD, and rendezvous technique)



































































































































































First author, year

n

Device for puncture

Technical success,n

Clinical success, n

Initial stent

Early complications ( n)

Plastic, French

SEMS, mm

EUS-guided choledochoduodenostomy

Giovannini 2001 [6]

1

NK

1/1

1/1

10


None

Burmester 2003 [7]

2

19G FT

1/2

1/1

8.5


Bile peritonitis (1)

Puspok 2005 [8]

5

NK

4/5

4/4

7− 10


None

Kahaleh 2006 [9]

1

19G FN

1/1

1/1
 
10

Pneumoperitoneum (1)

Yamao 2008 [10]

5

NK

5/5

5/5

7–8.5


Pneumoperitoneum (1)

Ang 2007 [11]

2

NK

2/2

2/2

7


Pneumoperitoneum (1)

Fujita [12]

1

19G FN

1/1

1/1

7


None

Tarantino 2008 [13]

4

19G, 22G FN/NK

4/4

4/4

a


None

Itoi 2008 [14]

4

NK (2), 19 G FN (2)

4/4

4/4

7, NBD


Bile peritonitis (1)

Horaguchi 2009 [15]

8

19G

8/8

8/8

7


Peritonitis (1)

Hanada 2009 [16]

4

19G FN

4/4

4/4

6–7


None

Park 2009 [17]

4

19G FN/NK

4/4

4/4


10

None

Brauer 2009 [18]

3

19G, 22G FN/NK

2/3

2/2

10


Pneumoperitoneum Cardiac failure

Maranki 2009 [19]

4

19G, 22G
 
0

10

10

0

Artifon 2010 [20]

3

19G

3/3

3/3


10

None

Eum 2010 [21]

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May 30, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on EUS-Guided Bilio-Pancreatic Drainage

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