EUS-guided biliary drainage: a case series

 

 Buy Article Permissions and Reprints

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is the most appropriate technique to treat common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Biliary and/or pancreatic duct cannulation and visualization are successful with ERCP in a high percentage of cases managed by experienced hands [1] [2] [3]. Common causes of failure include complex peripapillary diverticula, prior surgery procedures such as gastrectomy with Billroth II anastomosis, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones [4].

Percutaneous transhepatic cholangiography (PTC) [5] and surgery are the alternative approaches to access and drain obstructed ducts. The development of the large channel linear array echoendoscope allows for therapeutic procedures such as fine needle aspiration (FNA) and biopsy [6], celiac plexus neurolysis [7], pancreatic pseudocyst [8], and perirectal and retroperitoneal abscess drainage [9].

Since 1996 when Wiersema et al. first described endoscopic ultrasound (EUS)-guided bile duct puncture [10], several case reports have been published on EUS-guided biliary and pancreatic duct puncture and drainage [11] [12] [13] [14] [15] [16] [17] [18] [19]. These case reports illustrate different techniques to approach bile and pancreatic ducts: transgastric or transduodenal puncture, rendezvous after positioning a guide wire through the papilla, or creating a new papilla by fistula formation. In all of these reports, interventional EUS proved feasible and safe with a low rate of complications, but only few series have been published.

Kahaleh et al. have recently described a series of 23 patients treated with interventional endoscopic ultrasound cholangiography (IEUC). Biliary decompression was accomplished in more than 90 % of the cases that had previously received ERCP without success; in one of these cases, bile leakage occurred using the extrahepatic approach [20].

We describe a series of consecutive patients in whom ERCP failed for different reasons ([Table 1]), and IEUC was applied instead of the traditional percutaneous approach.

• 1 Ponchon T, Pilleul F. Diagnostic ERCP.  Endoscopy. 2002;  34 29-42
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Cortas G A, Mehta S N, Abraham N S, Barkun A N. Selective cannulation of the common bile duct: a prospective randomized trial comparing standard catheters with sphincterotomes.  Gastrointest Endosc. 1999;  50 775-779
  CrossrefPubMedGoogle Scholar
• 3 Schofl R. Diagnostic endoscopic retrograde cholangiopancreatography.  Endoscopy. 2001;  33 147-157
  Article in Thieme ConnectPubMedGoogle Scholar
• 4 Martin D F. Combined percutaneous and endoscopic procedures for bile duct obstruction.  Gut. 1994;  35 1011-1012
  CrossrefPubMedGoogle Scholar
• 5 Ferrucci Jr J T, Mueller P R, Harbin W P. Percutaneous transhepatic biliary drainage: technique, results, and application.  Radiology. 1980;  135 1-13
  Google Scholar
• 6 Wiersema M J, Vilmann P, Giovannini M. et al . Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment.  Gastroenterology. 1997;  112 1087-1095
  PubMedGoogle Scholar
• 7 Abedi M, Zfass A M. Endoscopic ultrasound-guided (neurolytic) celiac plexus block.  J Clin Gastroenterol. 2001;  32 390-393
  CrossrefPubMedGoogle Scholar
• 8 Baron T H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.  Gastrointest Endosc Clin N Am. 2003;  35 102-106
  PubMedGoogle Scholar
• 9 Giovannini M, Bories E, Moutardier V. et al . Drainage of deep pelvic abscesses using therapeutic echo endoscopy.  Endoscopy. 2003;  35 511-514
  Article in Thieme ConnectPubMedGoogle Scholar
• 10 Wiersema M J, Sandusky D, Carr R. et al . Endosonography-guided cholangiopancreatography.  Gastrointest Endosc. 1996;  43 102-106
  Google Scholar
• 11 Giovannini M, Moutardier V, Pesenti C. et al . Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.  Endoscopy. 2001;  33 898-900
  Article in Thieme ConnectPubMedGoogle Scholar
• 12 Puspo K A, Lomoschitz F, Dejaco C. et al . Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series.  Am J Gastroenterol. 2005;  100 1743-1747
  CrossrefPubMedGoogle Scholar
• 13 Kahaleh M, Yoshida C, Yeaton P. EUS antegrade pancreatography with gastropancreatic duct stent placement: review of two cases.  Gastroint Endosc. 2003;  58 919-923
  CrossrefPubMedGoogle Scholar
• 14 Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUS-cholangiodrainage of the bile duct: report of 4 cases.  Gastroint Endosc. 2003;  57 246-150
  Google Scholar
• 15 Mallery S, Matlock J, Freeman M L. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases.  Gastroint Endosc. 2004;  59 100-107
  Google Scholar
• 16 Kahaleh M, Yoshida C, Kane L, Yeaton P. Interventional EUS cholangiography: a report of five cases.  Gastroint Endosc. 2004;  60 138-142
  CrossrefPubMedGoogle Scholar
• 17 Will U, Meyer F, Manger T, Wanzar I. Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis.  Endoscopy. 2005;  37 171-173
  Article in Thieme ConnectPubMedGoogle Scholar
• 18 Lai R, Freeman M. Endoscopic ultrasound-guided bile duct access for rendezvous ERCP drainage in the setting of intra-diverticular papilla.  Endoscopy. 2005;  37 487-489
  Article in Thieme ConnectPubMedGoogle Scholar
• 19 Kahaleh M, Wang P, Shami V. et al . EUS-guided transhepatic cholangiography: report of 6 cases.  Gastrointest Endosc. 2005;  61 307-313
  CrossrefPubMedGoogle Scholar
• 20 Kahaleh M, Hernandez A J, Tokar J. et al . Interventional EUS-guided cholangiography: evaluation of a technique in evolution.  Gastrointest Endosc. 2006;  64 52-59
  Google Scholar

I. Tarantino,MD 

Department of Gastroenterology
Mediterranean Institute for Transplantation and Advanced Specialized Therapies

Via tricomi
Palermo 90100
Italy

Fax: +39-091-6665340

Email: itarantino@ismett.edu