Endoscopic Ultrasound-Guided Double Drainage: Hepaticogastric and Anterograde Transpapillary Approaches for Malignant Distal Biliary Obstruction – What Are the Benefits?

Aims Endoscopic ultrasound-guided hepaticogastrostomy (HGS) is a biliary drainage technique for patients with malignant distal biliary obstruction (MDBO) in cases of altered anatomy, duodenal stenosis, or insufficient retrograde drainage. Adding an anterograde stent through the transhepatic route to HGS (HGAS) may improve clinical success and long-term outcomes. This study aims to compare the results of HGS and HGAS techniques based on the location of the stenosis.

Methods This is a single-center observational study. We retrospectively evaluated all patients who underwent HGS or HGAS between 2019 and 2024 for malignant extrahepatic or combined intra- and extrahepatic stenosis. Patients with isolated intrahepatic stenosis, those who underwent anterograde drainage alone, or a rendezvous technique were excluded. Indications, the nature of the primary lesion, the presence of ascites or metastases, and technical characteristics were considered. The primary outcome was the clinical success rate, defined as the resolution of cholangitis or a 50% reduction in bilirubin levels within 7 days. Adverse event (AE) rates, obstruction rates, obstruction-free survival, and overall survival were also compared. A subgroup analysis using a Cox regression model and Log-Rank test was performed to evaluate various parameters over time.

Results A total of 117 patients underwent a transhepatic intervention. Exclusions included those who underwent a rendezvous technique (n=27), anterograde drainage alone (n=1), benign stenosis (n=4), isolated intrahepatic stenosis (n=16), and those with missing data (n=2). Data from 67 patients (57.3%) with MDBO who underwent either HGS (n=49, 73.1%) or HGAS (n=18, 26.9%) were analyzed.

The primary indication was cholangitis (59.7%), with transhepatic drainage performed due to duodenal stenosis (46.3%). Most patients had pancreatic cancer (65.7%). The cancers were predominantly metastatic (61.2%), and few had ascites (13.4%). The overall clinical success rate was 84.5%, with 88.2% in the HGAS group and 82.9% in the HGS group (p=0.611). The HGAS group included a higher proportion of combined intra- and extrahepatic stenoses (38.9% vs. 18.4%), which were more successfully drained with HGAS (85.7% vs. 57.1%, p=0.559).

The incidence of AEs was lower in the HGAS group (11.1% vs. 18.4%, p=0.477). Six patients required re-intervention for obstruction (9%), most within the first 3 months (83.3%). This included 1 patient (5.6%) in the HGAS group and 5 (10.2%) in the HGS group (p=0.555). No significant differences were observed in obstruction occurrence between the two groups (log-rank, p=0.547) or in median overall survival (85 days vs. 79 days, p=0.72).

Conclusions HGAS appears to offer a slightly higher clinical success rate than HGS for biliary drainage in MDBO patients, particularly in cases involving intra- and extrahepatic stenoses.

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Artikel online veröffentlicht:
27. März 2025