EUS-Guided Biliary Drainage for Malignant Biliary Duct Obstruction: Yokohama City University Experience

Background: For patients who had a failed ERCP, EUS-guided biliary drainage (EUS-BD) has been developed as an alternative to percutaneous method. Aim: To evaluate technical and clinical outcomes of EUS-BD in our institute. Methods: Retrospective study of consecutive patients who following failed ERCP underwent EUS-BD at Yokohama City University Hospital. EUS-guided transluminal (transgastric or transduodenal) biliary stenting was performed. An echoendoscope was inserted into the stomach or the duodenal bulb to puncture the bile duct by a 19-gauge needle. After insertion of a 0.035-inch guide wire, the puncture hole was dilated by dilation catheters (6&7Fr). A straight plastic stent (7Fr) was placed to make hepaticogstrostomy or choledochoduodenostomy. The main outcome measures were rate of technical success and safety profile of EUS-BD. Results: 6 patients underwent EUS-BD. 5 patients were carcinomas in periampullary lesion and one was a metastatic biliary tumor due to colon cancer. Reason for failure at ERCP were failed cannulation (distorted ampulla) in 4 patients, inability to identify the papillary orifice in one and duodenal mass precluding access to the ampulla in one. The access routes for the transluminal drainage were transgastric in one patient and transduodenal in 5. EUS-BD was technically successful in 4 of 6 patients (66.7%). Two failure cases were treated by percutaneous transhepatic gallbladder drainage. Complications were encountered in 4 of 6 patients (66.7%) who underwent EUS-BD via the transluminal approach that include bleeding required transfusion (n=1), self-limited bile leak (n=1), self-limited perforation (n=1) and stent migration (n=1). No procedure-related deaths occurred. Patients were followed-up for average 212 days. During the follow-up, 3 patients died while 1 are actually alived and two patients required endoscopic re-interventions included metallic stenting. Conclusions: EUS-BD is technically feasible for our institute, however, the rate of complication is high. EUS-BD may be a useful procedure for treatment obstructive jaundice when ERCP fails, but required skill and dedicated devices for technical success and to reduce the complications.