Original Article
Clinical Endoscopy
Interventional EUS-guided cholangiography: evaluation of a technique in evolution

https://doi.org/10.1016/j.gie.2006.01.063Get rights and content

Background

Interventional EUS-guided cholangiography (IEUC) has been increasingly used as an alternative to percutaneous transhepatic cholangiography (PTC) in cases of biliary obstruction when ERCP is unsuccessful.

Objective

We reviewed our experience and technique used for this procedure.

Design

Over a 3-year period, ending July 2005, patients with a failed ERCP were offered an IEUC.

Setting

Tertiary care center offering ERCP and interventional EUS.

Patients

Twenty-eight patients were candidates for IEUC. Two patients had bleeding masses and were referred to interventional radiology, 1 patient had a large mass occupying the duodenal lumen, and 2 patients refused IEUC.

Intervention

EUS was used to access the biliary system after which a guidewire was advanced antegrade across the obstruction. Either rendezvous with retrograde or antegrade drainage was then accomplished.

Main Outcome Measurements

Efficacy and safety of IEUC for biliary decompression.

Results

IEUC was successfully performed in 23 patients, with a transgastric-transhepatic (intrahepatic) approach in 13 cases and transenteric-transcholedochal (extrahepatic) approach in 10 cases. Therapeutic benefit was achieved in 21 patients: 18 underwent successful stent deployment across the stricture, whereas 3 patients required a choledochoenteric fistula formation. Complications included 1 case of bile leak, 2 cases of self-limited pneumoperitoneum, and 1 case of minor bleeding.

Limitations

Single-center experience of 2 operators.

Conclusions

IEUC appears efficacious in patients in whom ERCP is unsuccessful and is evolving as an attractive alternative to PTC. Intrahepatic access to the biliary system appears safer than the extrahepatic approach.

Section snippets

Methodology

All patients who presented with obstructive jaundice and who underwent IEUC after a failed ERCP during a 3-year study period were entered in this study. Failed ERCP was defined as failed cannulation or an inability to relieve symptomatic jaundice. A total of 3501 ERCPs were performed during the study period, of which 1519 required biliary decompression. Of these 1519 patients, 1365 successfully underwent conventional biliary drainage (90%), 126 required pre-cut techniques (8%), and the

Results

A total of 23 patients were included in this study, 12 women and 11 men. The mean age was 61.5 ± 11.7 years. All patients had successful EUS-assisted cholangiography with definition of the relevant anatomy.

Eighteen patients underwent intrahepatic cholangiography, with conversion to an extrahepatic intervention in 5 patients (27%). Of the 13 patients who underwent intrahepatic intervention, 11 had a stent placed across the major papilla. One patient had a cholangiogastric fistula created with

Discussion

Biliary obstruction is preferentially managed by ERCP.3 Failure of ERCP is related to tumor extension,21 prior surgery,6 or incomplete drainage.22 Alternatives after failed ERCP include percutaneous transhepatic drainage and surgery. Percutaneous transhepatic drainage has a complication rate of up to 32%, including fistula formation, cholangitis, peritonitis, empyema, hematoma, and liver abscesses.23, 24 Surgery offers long-term patency but is associated with increased morbidity and mortality.25

References (29)

  • E.L. Fogel et al.

    Therapeutic biliary endoscopy

    Endoscopy

    (2001)
  • R. Schofl

    Diagnostic endoscopic retrograde cholangiopancreatography

    Endoscopy

    (2001)
  • D.L. Carr-Locke

    Overview of the role of ERCP in the management of diseases of the biliary tract and the pancreas

    Gastrointest Endosc

    (2002)
  • K. Huibregtse et al.

    Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and endoscopic biliary and pancreatic drainage

  • D.N. Lobo et al.

    Periampullary diverticula: consequences of failed ERCP

    Ann R Coll Surg Engl

    (1998)
  • B.E. Wright et al.

    ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla

    Gastrointest Endosc

    (2002)
  • C.P. Choudari et al.

    Success of ERCP at a referral center after a previously unsuccessful attempt

    Gastrointest Endosc

    (2000)
  • J.T. Ferrucci et al.

    Percutaneous transhepatic biliary drainage: technique, results, and applications

    Radiology

    (1980)
  • W.P. Harbin et al.

    Transhepatic cholangiography: complications and use patterns of the fine-needle technique: a multi-institutional survey

    Radiology

    (1980)
  • A.C. Smith et al.

    Randomised trial of endoscopic stenting versus surgical bypass in malignant low bile duct obstruction

    Lancet

    (1994)
  • T. Rösch et al.

    Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography. Comparison with conventional sonography, computed tomography, and angiography

    Gastroenterology

    (1992)
  • M.J. Wiersema et al.

    Endosonography-guided real-time fine-needle aspiration biopsy

    Gastrointest Endosc

    (1994)
  • M.J. Wiersema et al.

    Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment

    Gastroenterology

    (1997)
  • N.A. Ahmad et al.

    Role of endoscopic ultrasound and magnetic resonance imaging in the preoperative staging of pancreatic adenocarcinoma

    Am J Gastroenterol

    (2000)

    • Cited by (0)

    Part of this work was presented as a poster at Digestive Disease Week, Chicago, Illinois, May 14-18, 2005. Gastrointest Endosc 2005;61:AB285.

    View full text
    Copyright © 2006 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.