EUS guided drainage of the biliary tree is effective and safe for both benign and malignant indications: A multicentre study.

Abstract

Background and aims: In the majority of benign and malignant causes of biliary obstruction, drainage can be achieved via endoscopic retrograde cholangiography (ERC). However, in cases of failed ERC, the management algorithm usually encompasses percutaneous transhepatic cholangiography (PTC) or surgical bypass. The latter two are associated with significant morbidity. Therefore, a minimally invasive approach is preferable. The evolution of therapeutic EUS has permitted development of novel drainage techniques without the need for external drainage catheters or major surgery. The aim of this study is to evaluate outcomes of EUS-drainage procedures in benign and malignant causes of biliary obstruction. Method(s): This is a multicentre, retrospective review of all patients undergoing EUS-guided intervention to achieve drainage of the biliary tree. Patient demographics, procedural technical data, pre- and post- procedure bilirubin and adverse events were recorded. Technical success was defined as placement of stent in intended location. Clinical success was defined as >50% decline in bilirubin 2 weeks post procedure. Result(s): Between October 2013 and May 2016, a total of 14 patients, (mean age 63 +/- 19 years, 8/14 male) underwent EUS-biliary drainage procedures at 3 tertiary academic centres. Majority (72%) were for malignant obstruction (pancreatic cancer, n = 6, cholangiocarcinoma, n = 2, colorectal cancer metastasis, n = 2) and 28% (4/14) were for benign disease (benign biliary stricture, n = 2, cholangitis, n = 1, cholecystitis, n = 1). Reasons for failed ERC included obscured ampulla (n = 4), gastric outlet obstruction (n = 3), failed deep wire cannulation (n = 5), 1 ampulla within diverticulum and 1 patient unfit for laparoscopic cholecystectomy. EUS-guided drainage was performed via extrahepatic access in 64% (9/14) of cases. Seven choledochoduodenostomies, 4 hepatogastrostomies, 1 rendezvous, 1 antegrade stent and 1 gallbladder drainage were performed. Tract dilatation was performed with tapered tip balloon dilators in majority of cases 64% (9/14) whereas cautery was used in only 36% (5/14) cases. Fully covered biliary stents were used in 12/14 (86%), 1 patient (7%) had a pseudocyst stent for performing choledochoduodenostomy and 1 patient had plastic stent. Technical success was achieved in 86% (12/14) cases. Clinical success was achieved in 11/12 (92%) of technically successful cases (mean bilirubin 175.7 vs. 61.5, P = 0.005, pre- and post- procedure respectively). Reasons for failure included obscured access due to preexisting PTC and loss of wire position during rendezvous endoscope exchange, ongoing sepsis. Mean procedure time was 68.85 mins (range 20-148 mins). During mean follow-up of 235 days (range 2-1045 days), stent patency rate was 100%. Adverse event rate was 7%, 1 patient had self-limiting post procedure pain and there were 2 deaths (unrelated to procedure). Conclusion(s): In patients with failed ERC, EUS guided drainage is a safe and effective, minimally invasive alternative to PTC or surgical bypass in both benign and malignant conditions.