Aims Percutaneous transhepatic biliary drainage (PTBD) is associated with significant
morbidity and prolonged hospital stay [1,2]. Endosonography-guided biliary drainage
(EUS-BD) is an alternative to PTBD when endoscopic retrograde pancreatography (ERCP)
has failed. The aims of this study were to review the technical success and adverse
events with EUS-BD procedures performed at a tertiary care referral centre.
Tab. 1
Failures and complications
|
Procedure
|
No. of procedures
|
Aetiology: Benign/Malignant
|
Technical success
|
Failures/Complications
|
|
Choledochoduodenostomy (CDD) using lumen-apposing metal stent (LAMS)
|
56
|
6/50
|
98.2%
|
1 failed: ♣ Patient underwent PTBD Complications: ♣ LAMS migration out of duct in
1 patient 4 weeks later with persistent fistula providing biliary drainage ♣ 2 maldeployments
(rescued with FCSEMS through LAMS)
|
|
CBD rendezvous
|
14
|
14/0
|
78.6%
|
3 failed: ♣ 2 patients underwent CDD ♣ 1 patient underwent PTBD Complications: ♣ Bile
leak in 1 patient
|
|
Hepaticogastrostomy
|
12
|
1/11
|
100%
|
Complications: ♣ Delayed bleeding from stent insertion site in 1 patient ♣ Cholangitis
in 1 patient
|
Methods A prospectively-collected database of EUS-BD procedures performed from 1st August
2016 to 20th November 2019 was reviewed retrospectively. Recorded variables were technical
success, adverse events, length of stay and 30-day all-cause mortality.
Results A total of 82 procedures were performed. 45 patients were male (55%); median age
70 years (range 20-90).
Indications for drainage were pancreatobiliary malignant obstruction (n =55), choledocholithiasis
(n=14), other metastatic malignancies (n=7), chronic pancreatitis (n=5) and benign
duodenal stricture (n=1).
Reasons for failed ERCP were inaccessible papilla (gastric outlet obstruction; n=29),
tumour infiltration of ampulla (n=26), obscured intradiverticular ampulla (n=16) and
failure to transverse biliary stricture (n=11).
The route of attempted biliary drainage was choledochoduodenostomy in 56, EUS-guided
rendezvous in 14 and hepaticogastrostomy in 12.
The procedures were technically successful in 95.1%. Adverse event (AE) rate was 7.3%.
Failures and AEs are detailed in table. Median hospital-stay was 3 days (range 0-120
days). 2 patients died within 30 days, both of multiorgan failure due to pre-existing
sepsis non-responsive EUS-BD.
Table
Conclusions This study adds to the existing literature supporting EUS-BD [3-5] as an effective
alternative to PTBD after failed ERCP. The rendezvous technique seems less successful
in this series. Further prospective randomised studies are needed to compare outcomes
for EUS-guided versus percutaneous drainage.
