Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography

Background and study aims: Endoscopic retrograde cholangiography (ERC) with stenting is the procedure of choice for biliary decompression in patients with obstructive jaundice. In cases where biliary access cannot be achieved, interventional endoscopic ultrasound-guided cholangiography (IEUC) has become an alternative to percutaneous transhepatic cholangiography (PTC).

Patients and methods: We report on 5 years of experience in patients who underwent IEUC after failed endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided access to the targeted biliary duct was attempted with one of two approaches: transgastric–transhepatic (intrahepatic) or transenteric–transcholedochal (extrahepatic). A stent was then advanced over the wire and into the biliary tree.

Results: A total of 49 patients underwent IEUC: 35 had biliary obstruction due to malignancy and 14 had a benign etiology. The overall success rate of IEUC was 84 % (41 / 49), with an overall complication rate of 16 %. Of the 35 patients who underwent the intrahepatic approach, 23 had a stent placed across the major papilla, one had a stent placed intraductally in the common bile duct, and three patients underwent placement of a gastrohepatic stent. Resolution of obstruction was achieved in 29 patients, with a success rate of 83 %. In all, 14 patients underwent an extrahepatic approach. In 8 / 14 (57 %), stent placement across the major papilla was achieved. A transenteric stent was placed in four patients. Biliary decompression was achieved in 12 / 14 cases (86 %). Based on intention-to-treat analysis, the intrahepatic approach achieved success in 29 of 40 cases (73 %), and the extrahepatic approach was successful in seven of nine cases (78 %). There were no procedure-related deaths.

Conclusion: IEUC offers a feasible alternative to PTC in patients with obstructive jaundice in whom ERC has failed.

References

• 1 Fogel E L, Sherman S, Devereaux B M, Lehman G A. Therapeutic biliary endoscopy.  Endoscopy. 2001;  33 31-38
• 2 Schofl R. Diagnostic endoscopic retrograde cholangiopancreatography.  Endoscopy. 2001;  33 147-157
• 3 Carr-Locke D L. Overview of the role of ERCP in the management of diseases of the biliary tract and the pancreas.  Gastrointest Endosc. 2002;  56 157-160
• 4 Huibregtse K, Kimmey M B. Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and endoscopic biliary and pancreatic drainage. In: Yamada T, ed Textbook of gastroenterology. Philadelphia; J.B. Lippincott 1995: 2590-2617
• 5 Martin D F. Combined percutaneous and endoscopic procedures for bile duct obstruction.  Gut. 1994;  35 1011-1012
• 6 Lobo D N, Balfour T W, Iftikhar S Y. Periampullary diverticula: consequences of failed ERCP.  Ann R Coll Surg Engl. 1998;  80 326-331
• 7 Wright B E, Cass O W, Freeman M L. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla.  Gastrointest Endosc. 2002;  56 225-232
• 8 Kumar S, Sherman S, Hawes R H, Lehman G A. Success and yield of second attempt ERCP.  Gastrointest Endosc. 1995;  41 445-447
• 9 Choudari C P, Sherman S, Fogel E L. et al . Success of ERCP at a referral center after a previously unsuccessful attempt.  Gastrointest Endosc. 2000;  52 478-483
• 10 Martin D F, Tweedle D E. Risks of precut papillotomy and the management of patients with duodenal perforation.  Am J Surg. 1992;  163 273-274
• 11 Siegel J H. Precut papillotomy: a method to improve success of ERCP and papillotomy.  Endoscopy. 1980;  12 130-133
• 12 Ferrucci Jr. J T, Mueller P R, Harbin W P. Percutaneous transhepatic biliary drainage: technique, results, and applications.  Radiology. 1980;  135 1-13
• 13 Harbin W P, Mueller P R, Ferrucci Jr. J T. Transhepatic cholangiography: complicatons and use patterns of the fine-needle technique: a multi-institutional survey.  Radiology. 1980;  135 15-22
• 14 Calvo M M, Bujanda L, Heras I. et al . The rendezvous technique for the treatment of choledocholithiasis.  Gastrointest Endosc. 2001;  54 511-513
• 15 Smith A C, Dowsett J F, Russell R C. et al . Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction.  Lancet. 1994;  344 1655-1660
• 16 Lameris J S, Stoker J, Nijs H G. et al . Malignant biliary obstruction: percutaneous use of self-expandable stents.  Radiology. 1991;  179 703-707
• 17 Beissert M, Wittenberg G, Sandstede J. et al . Metallic stents and plastic endoprostheses in percutaneous treatment of biliary obstruction.  Z Gastroenterol. 2002;  40 503-510
• 18 Kama N A, Coskun T, Yuksek Y N, Yazgan A. Factors affecting post-operative mortality in malignant biliary tract obstruction.  Hepatogastroenterology. 1999;  46 103-107
• 19 Grimm H, Binmoeller K F, Soehendra N. Endosonography-guided drainage of a pancreatic pseudocyst.  Gastrointest Endosc. 1992;  38 170-171
• 20 Wiersema M J. Endosonography-guided cystoduodenostomy with a therapeutic ultrasound endoscope.  Gastrointest Endosc. 1996;  44 614-617
• 21 Wiersema M J, Wiersema L M. Endosonography-guided celiac plexus neurolysis.  Gastrointest Endosc. 1996;  44 656-662
• 22 Abedi M, Zfass A M. Endoscopic ultrasound-guided (neurolytic) celiac plexus block.  J Clin Gastroenterol. 2001;  32 390-393
• 23 Gress F, Schmitt C, Sherman S. et al . Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience.  Am J Gastroenterol. 2001;  96 409-416
• 24 Collins D, Penman I, Mishra G, Draganov P. EUS-guided celiac block and neurolysis.  Endoscopy. 2006;  38 935-939
• 25 Michaels A J, Draganov P V. Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis.  World J Gastroenterol. 2007;  13 3575-3580
• 26 Giovannini M, Moutardier V, Pesenti C. et al . Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.  Endoscopy. 2001;  33 898-900
• 27 Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUS-cholangio-drainage of the bile duct: report of 4 cases.  Gastrointest Endosc. 2003;  57 246-251
• 28 Mallery S, Matlock J, Freeman M L. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases.  Gastrointest Endosc. 2004;  59 100-107
• 29 Kahaleh M, Yoshida C, Kane L, Yeaton P. Interventional EUS cholangiography: A report of five cases.  Gastrointest Endosc. 2004;  60 138-142
• 30 Puspok A, Lomoschitz F, Dejaco C. et al . Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series.  Am J Gastroenterol. 2005;  100 1743-1747
• 31 Kahaleh M, Hernandez A J, Tokar J. et al . Interventional EUS-guided cholangiography: evaluation of a technique in evolution.  Gastrointest Endosc. 2006;  64 52-59
• 32 Kahaleh M, Wang P, Shami V M. et al . EUS-guided transhepatic cholangiography: report of 6 cases.  Gastrointest Endosc. 2005;  61 307-313
• 33 Ponnudurai R, Giovannini M, Deviere J. et al . EUS guided hepatico gastrostomy [abstract].  Gastrointest Endosc. 2004;  58 AB4
• 34 Bories E, Pesenti C, Caillol F. et al . Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study.  Endoscopy. 2007;  39 287-291
• 35 Will U, Thieme A, Fueldner F. et al . Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage.  Endoscopy. 2007;  39 292-295
• 36 Tarantino I, Barresi L, Repici A, Traina M. EUS-guided biliary drainage: a case series.  Endoscopy. 2008;  40 336-339
• 37 Yamao K, Bhatia V, Mizuno N. et al . EUS-guided choledochoduodenostomy for palliative biliary drainage in patients with malignant biliary obstruction: results of long-term follow-up.  Endoscopy. 2008;  40 340-342