Endoscopic biliary drainage in patient with Surgically-alTeREd anaTomy: the STREeT multicenter Italian study

Aims Endoscopic biliary drainage (BD) in patients with altered anatomy is a challenging scenario, reducing the chance of clinical success compared to standard anatomy. The choice between different BD approaches is still not standardized and relies on local availability and expertise. Aim of this study was to explore the approach to BD in patients with altered anatomy in different Italian centers, including the number of attempts.

Methods this was a retrospective multicenter cohort study within the i-EUS network of biliopancreatic endoscopy. All adult patients with upper GI altered anatomy who underwent endoscopic BD for any indication in the last 5 years were enrolled. Surgical reconstruction were divided in Billroth II patients (including those with pancreatoduodenectomy) and Roux-en-y patients (including those with hepaticojejunostomy). Fisher’s exact test and Mann-Whitney test were used when appropriate.

Results 19 centers participated in the study. All centers were equipped for interventional endoscopic ultrasound (EUS) whereas only 6 centers had also the availability of device-assisted enteroscopy (DAE). 360 patients were enrolled. Indication to BD was not different between patients with Billroth-II (B-II, N=231) or Roux-en-Y (RY, N=120) reconstructions. 19% of patients had at least one previous failed BD attempt. B-II anatomies were more frequently managed transpapillary with a duodenoscope or a forward viewing scope (86.3%), whereas in case of RY reconstruction BD approach was more heterogeneous. In 58% of RY cases, a retrograde approach was performed (in>50% of cases with standard scopes). Among the 20.1% undergoing EUS-BD in RY patients, hepaticogastrostomy or antegrade stenting were performed in 71% of cases mostly for malignant indications (90%). Type of surgical reconstruction did not affect the clinical success (86% in BII and 82% in RY, p=ns). Interventional EUS tended to higher clinical success compared to DAE (94% vs 81%, p=0.07). The total number of procedures to achieve clinical success was similar between B-II and RY patients. Patients who failed endoscopic BD for whom follow-up was available, were managed by PTBD or surgery in 71% and 15% of cases respectively.

Conclusions Endoscopic BD in altered anatomy has a sub-optimal clinical success compared to standard anatomy. A relevant proportion of patients requires more than one endoscopic attempt to achieve the clinical success. Despite the recent advent, interventional EUS is optioned in many centers and demonstrated a high efficacy in patients with altered anatomy.

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Artikel online veröffentlicht:
15. April 2024