Reply to Fabbri et al.

We thank Prof Fabbri and welcome his comments on our article entitled “Comparison of the clinical impact of endoscopic ultrasound-guided choledochoduodenostomy and hepaticogastrostomy for bile duct obstruction” [1].

As mentioned, we used partially covered metal stents (1 cm uncovered, 9 or 11 cm covered) for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), and fully covered metal stents for EUS-guided choledochoduodenostomy (EUS-CDS). However, in EUS-HGS, the uncovered portion plays a role only in the prevention of stent migration, and the difference in the type of metal stent should not affect stent patency. In addition, in our study, stent migration was not seen in either group. Therefore, our results may be due to the drainage route used rather than to any difference in the type of metal stent used. On the other hand, the length of the luminal portion of the stent may be an important point in the prevention of stent migration and cholangitis, and in achieving longer stent patency [2].

On endoscopic retrograde cholangiopancreatography (ERCP), the rate of cholangitis is reported to be higher in patients with obstructive jaundice with duodenal obstruction than in those without duodenal obstruction [3] [4]. EUS-CDS may therefore carry a risk of cholangitis via the same mechanism. In addition, the stomach represents a wide space compared with the duodenum, so the intraluminal pressure may be lower. We have in fact ourselves seen cholangitis occurring after EUS-CDS with duodenal stenting. The patient underwent EUS-HGS using a conversion method [5], following which cholangitis did not occur again. Therefore, we recommend that EUS-HGS should be performed in patients with obstructive jaundice complicated by duodenal obstruction, if this procedure is performed by an experienced endoscopist.

The Axios stent may be suitable for EUS-CDS as mentioned; however, this stent has a large diameter, therefore flow of food may occur through it. Longer follow-up results are needed to advance to randomized controlled trials of EUS-HGS vs. EUS-CDS.

Finally, EUS-guided biliary drainage (EUS-BD) is still a risky procedure, so technical tips and device improvements to enable us to perform EUS-BD safely are definitely needed. We think that currently EUS-BD is not strongly recommended.

• References

• 1 Ogura T, Chiba Y, Masuda D et al. Comparison of the clinical impact of endoscopic ultrasound-guided choledochoduodenostomy and hepaticogastrostomy for bile duct obstruction with duodenal obstruction. Endoscopy 2016; 51: 360-367
• 2 Ogura T, Yamamoto K, Sano T et al. Stent length is impact factor associated with stent patency in endoscopic ultrasound-guided hepaticogastrostomy. J Gastroenterol Hepatol 2015; 30: 1748-1752
• 3 Hamada T, Isayama H, Nakai Y et al. Duodenal invasion is a risk factor for the early dysfunction of biliary metal stents in unresectable cancer. Gastrointest Endosc 2011; 74: 317-321
• 4 Hamada T, Nakai Y, Isayama H et al. Duodenal metal stent placement is risk factor for biliary metal stent dysfunction: an analysis using a time-dependent covariate. Surg Endosc 2013; 27: 1243-1248
• 5 Ogura T, Sano S, Onda S et al. A novel technique for treating cholangitis following EUS-CDS. Am J Gastroenterol 2014; 109: 1527