Case series
Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips
Authors
Takeshi Ogura1, Tatsushi Sano1, Saori Onda1, Akira Imoto1, Daisuke Masuda1, Kazuhiro Yamamoto2, Masayuki Kitano3, Toshihisa Takeuchi1, Takuya Inoue1, Kazuhide Higuchi1
Institutions
1
2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan Department of Radiology, Osaka Medical College, Osaka, Japan 3 Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan 2
submitted 26. May 2014 accepted after revision 4. August 2014
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1378111 Published online: 29.9.2014 Endoscopy 2015; 47: 72–75 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Takeshi Ogura, PhD, MD 2nd Department of Internal Medicine Osaka Medical College 1-1 Daigakuchou, Takatsukishi Osaka 464-8681 Japan Fax: +81-527635233 [email protected]
Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is not normally indicated for an obstructed right intrahepatic bile duct (IHBD). The technical feasibility and clinical efficacy of a novel technique of EUS-BD for right IHBD obstruction were evaluated. A total of 11 patients underwent drainage using either a left or a right biliary access route. The causes of obstructive jaundice were cholangiocarcinoma (n = 6), pancreatic can-
cer (n = 3), gastric cancer (n = 1), and colon cancer (n = 1). After placement of an uncovered metal stent to bridge the obstruction, a hepaticogastrostomy was completed using a covered stent. Mean procedure time was 33.9 ± 10.0 minutes. Technical and functional success were achieved in all patients, and no adverse events occurred. This novel method appears to be safe and effective for right IHBD obstruction.
Introduction
Patients and methods
!
!
Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) has been developed as an alternative technique for cases of failed endoscopic biliary drainage, percutaneous transhepatic biliary drainage, or inaccessible papilla [1, 2]. Generally, this novel method, especially EUS-guided hepaticogastrostomy, has been indicated for extrahepatic bile duct obstruction, or for isolated left intrahepatic bile duct (IHBD) obstruction because only the left IHBD can be punctured to access the IHBD tree using transgastric EUS imaging. Therefore, hepatic hilar obstruction and isolated right IHBD obstruction are not normally indications for EUS-guided hepaticogastrostomy. A recent report described EUS-BD for isolated right IHBD obstruction [3], with antegrade stenting using uncovered metal stents or bypass stenting using fully covered metal stents. However, antegrade stenting carries the risk of bile leakage from the fistula, and bypass stenting may result in branch bile duct occlusion from use of the fully covered metal stent. The aim of the current pilot study was to evaluate the technical feasibility and clinical efficacy of a novel technique of EUS-BD for biliary obstruction involving the right hepatic bile duct.
Patients who were histologically diagnosed as having unresectable carcinoma and obstructive jaundice due to an obstructed right IHBD were included in this study from June 2012 to February 2014. Patients provided written informed consent to all procedures associated with the study.
Ogura Takeshi et al. Endoscopic ultrasound-guided biliary drainage … Endoscopy 2015; 47: 72–75
Protocol for EUS-guided biliary drainage One therapeutic endoscopist (T.O.), who was trained and experienced in both EUS and endoscopic retrograde cholangiopancreatography (ERCP), performed the procedures. All patients were given antibiotics before undergoing procedure. The IHBD was imaged at a frequency of 7.5 MHz using a convex echoendoscope (GFUGT260; Olympus Optical Co. Ltd., Tokyo, Japan) connected to an ultrasound device (SSD5500; Aloka, Tokyo, Japan). This novel technique of EUS-BD was applied using either a left or a right biliary access route.
Left biliary access route
" Fig. 1, ● " Video 1) (● The echoendoscope was advanced into the stomach and the left IHBD was visualized. The left IHBD was then punctured using a 19-G needle (Sono Tip Pro Control 19G; Medi-Globe GmbH, Rosenheim, Germany). After aspiration of bile juice, contrast medium was injected and images of the biliary tree were obtained. Then, a 0.025-
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
72
Case series
73
Fig. 2 Locking stent method. a Uncovered metal stent between the right intrahepatic bile duct and the hepatic parenchyma (arrow). b The delivery system is inserted into the uncovered metal stent (red arrow, end of the uncovered metallic stent; yellow arrow, delivery system of the fully covered metal stent). c An uncovered metal stent is placed from the intestine to the hepatic parenchyma. d A fully covered metal stent is then placed from the proximal end of the uncovered metal stent to the duodenal bulb or stomach.
inch stiff guidewire (VisiGlide; Olympus Medical Systems, Tokyo, Japan) was inserted, and a standard ERCP catheter (MTW Endoskopie, Düsseldorf, Germany) replaced the 19-G needle. An attempt was then made to advance the guidewire into the right " Fig. 1 a). If the guidewire could not be advanced into IHBD (● the right IHBD, it was exchanged for a controllable ERCP cannula in order to negotiate the axis between the right IHBD and the ERCP catheter. Next, the delivery system for the uncovered metal stent was inserted (6-Fr delivery, 1 cm × 6 cm, Zilver 635 Biliary Self-Expanding Stent; Cook Medical, Bloomington, Indiana, USA) " Fig. 1 b). After placement of this stent between the right and (● left IHBDs (bridging method), EUS-guided hepaticogastrostomy was performed from the left intrahepatic bile duct to the stomach using a fully covered self-expandable metal stent (end bare type, Niti-S biliary covered stent; TaeWoong Medical, Seoul, Korea) " Fig. 1 c). (● " Fig. 2, ● " Video 2) Right biliary access route (●
The echoendoscope was advanced into the antrum or duodenal bulb. Using counterclockwise rotation, the right IHBD was visualized. To prevent branch bile duct obstruction or bile leakage, double metal stents (locking stent method) were used, as previously described [4]. After puncturing the right IHBD, the uncovered metal stent (Bile Rush; Piolax Medical Devices Inc., Kanagawa, Japan) was placed to bridge the obstruction of the right system to-
" Fig. 2 a,c). A fully covered wards the right hepatic parenchyma (● metal stent was then placed from the proximal end of the uncov" Fig. 2 b,d). ered metal stent to the duodenal bulb or stomach (●
Results !
● Table 1 shows the patient characteristics. The right biliary ac"
cess method was performed in four patients and the left biliary access was used in seven patients. The causes of obstructive jaundice were cholangiocarcinoma (n = 6), pancreatic cancer (n = 3), gastric cancer (n = 1), and colon cancer (n = 1). The reasons for left biliary access were duodenal obstruction (n = 5) and altered anatomy (n = 2), and the reasons for right biliary access were also duodenal obstruction (n = 1), altered anatomy (n = 1), as well as inability to advance the guidewire to the bile duct (n = 2). Access sites for the right route were the antrum (n = 3) and duodenal bulb (n = 1). For left biliary access, a standard ERCP cannula was successfully used in five patients and a controllable ERCP cannula was used in two patients. The mean procedure time was 33.9 ± 10.0 minutes. Total serum bilirubin was significantly decreased after this procedure (from 8.7 ± 2.7 mg/dL to 1.7 ± 1.0 mg/dL; P < 0.05). Technical success was achieved in all patients. No adverse events occurred during a mean follow-up of 4.1 months. Seven patients died from progressive disease.
Ogura Takeshi et al. Endoscopic ultrasound-guided biliary drainage … Endoscopy 2015; 47: 72–75
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Fig. 1 Bridging method. a Using a controllable endoscopic retrograde cholangiopancreatography cannula, the guidewire is advanced into the right hepatic bile duct. b The uncovered metal stent is placed. c Finally, a metal stent is placed from the left hepatic bile duct to the stomach.
Case series
Table 1
Patient characteristics.
Patient #
Type of
Indication
Obstruction
Age, years
cancer
for EUS-BD
site
Puncture site
Drainage method
Dilation
Proce-
Adverse
Follow-up
of fistula
dure
events,
period, days/
time
Early/
clinical
Late1
course
Sex
#1 78 Female
Pancreatic
Duodenal obstruction
Hepatic hilum
Right IHBD from stomach
Locking stent method
None
27
None/ None
88/Dead
2 76 Male
Bile duct
Altered anatomy
Hepatic hilum
Right IHBD from stomach
Locking stent method
Balloon dilation
32
None/ None
189/Alive
3 67 Male
Bile duct
Could not advance the guidewire to the anterior bile duct under ERCP
Right hepatic bile duct
Anterior bile duct from duodenal bulb
Locking stent method
None
22
None/ None
111/Dead
4 63 Female
Bile duct
Could not advance the guidewire to the posterior bile duct under ERCP
Right hepatic bile duct
Posterior bile duct from stomach
Locking stent method
Diathermic dilator
29
None/ None
147/Alive
5 66 Male
Pancreatic
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
31
None/ None
109/Alive
6 68 Female
Bile duct
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
49
None/ None
77/Dead
7 77 Female
Bile duct
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
25
None/ None
92/Alive
8 60 Female
Colon
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
33
None/ None
129/Dead
9 40 Female
Gastric
Altered anatomy
Hepatic hilum
Left IHBD from stomach
Bridging method using controllable ERCP cannula
Balloon dilation
32
None/ None
144/Dead
10 63 Male
Pancreatic
Altered anatomy
Hepatic hilum
Left IHBD from stomach
Bridging method using controllable ERCP cannula
Balloon dilation
55
None/ None
133/Dead
11 89 Female
Cholangio
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
38
None/ None
127/Dead
EUS-BD, endoscopic ultrasound-guided biliary drainage; IHBD, intrahepatic bile duct; ERCP, endoscopic retrograde cholangiopancreatography. 1 Early adverse event = within 1 week after the procedure; late adverse event = more than 1 week after the procedure.
Video 1
Online content including The left intrahepatic bile duct is punctured, and contrast medium is video sequences viewable injected. The guidewire is then inser- at: www.thieme-connect.de ted into the bile duct. Using an endoscopic retrograde cholangiopancreatography catheter, the guidewire is advanced into the intestine. The 6-Fr delivery system is successfully inserted without a dilation fistula, and the metal stent is placed above the ampulla of Vater. Finally, endoscopic ultrasound-guided hepaticogastrostomy is performed.
Video 2
Online content including From the duodenal bulb, the right video sequences viewable intrahepatic bile duct is visualized at: www.thieme-connect.de and punctured using a 19-G fineneedle aspiration needle. Contrast medium is injected to visualize the biliary tree. The guidewire is then inserted and advanced into the intestine using an endoscopic retrograde cholangiopancreatography catheter. The uncovered metal stent is then placed between the intestine and the hepatic parenchyma. Next, the delivery system for the fully covered metal stent is inserted into the uncovered metal stent, and the fully covered metal stent is placed for drainage into the duodenum.
Ogura Takeshi et al. Endoscopic ultrasound-guided biliary drainage … Endoscopy 2015; 47: 72–75
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
74
Case series
!
For transduodenal EUS-BD, EUS-guided choledochoduodenostomy is performed, in which the common bile duct is punctured and a stent is placed from the bile duct to the duodenum [5 – 7]. This approach is not indicated for cases of duodenal obstruction caused by tumor invasion or surgically altered anatomy. Transgastric EUS-BD is typically performed by accessing the left biliary system from the stomach with stent placement from the left IHBD to the stomach. In the current study, a novel technique of EUS-BD for right IHBD obstruction was applied. Technical and functional success were achieved in all patients. In addition, no severe adverse events occurred. However, this method has potential complications, such as bile leak, stent migration, and infection. Stent dysfunction may be of particular concern with the right-sided biliary access, due to the sharp angle encountered during stent delivery. Technically, this method has several important features. First, from the left access route, it is sometimes challenging to advance the guidewire into the right IHBD. It was very difficult to advance the guidewire into the right IHBD using a standard ERCP cannula in two patients, because of difficulty in aligning the axis to the right-sided bile duct. This challenge was overcome by using a controllable ERCP cannula. Second, stent selection is important. If a fully covered metal stent is selected in the hepatic hilum or right IHBD, a side branch may be occluded. There is also the possibility that misplacement may occur due to stent shortening. Therefore, the uncovered and laser-cut type metal stent was considered to be the most suitable stent type. In addition, a fine stent gauge and effective delivery system are also needed. Third, placement of only one metal stent, which was placed from the IHBD to the stomach or duodenum, without a fully covered
metal stent may risk bile leakage from a fistula. In addition, if only an uncovered metal stent is placed, reintervention following stent occlusion would sometimes be challenging. If occlusion of the uncovered metal stent were to occur, the presented double stent technique would enable straightforward reintervention through the covered stent. Although the present study has several limitations, such as small sample size, patient selection bias, single operator, and only a single arm, this method appears to be safe and effective for right IHBD obstruction. Validation is required in a prospective clinical trial. Competing interests: None
References 1 Fogel EL, Sherman S, Devereaux BM et al. Therapeutic biliary endoscopy. Endoscopy 2001; 33: 31 – 38 2 Itoi T, Isayama H, Sofuni A et al. Stent selection and tips on placement technique of EUS-guided biliary drainage: transduodenal and trans gastric stenting. J Hapatobiliary Pancreatic Sci 2011; 18: 664 – 672 3 Park SJ, Choi JH, Park do H et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc 2013; 78: 374 – 380 4 Ogura T, Kurisu Y, Masuda D et al. A novel method of EUS-guided hepaticogastrostomy to prevent stent dysfunction. J Gastroenterol Hepatol In press 2014: Doi: DOI 10.1111/jgh.12598 [Epub ahead of print] 5 Sarkaria S, Sundarajan S, Kahaleh M. Endoscopic ultrasonograhic access and drainage of the common bile duct. Gastrointest Endosc Clin N Am 2013; 23: 435 – 452 6 Kawakubo K, Isayama H, Kato H et al. Multicenter retrospective study of ultrasound-guided biliary drainage for malignant biliary obstruction in Japan. J Hepatobilliary Pancreat Sci 2014; 21: 328 – 334 7 Park DH, Koo JE, Oh J et al. EUS-guided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study. Am J Gastroneterol 2009; 104: 2168 – 2174
Ogura Takeshi et al. Endoscopic ultrasound-guided biliary drainage … Endoscopy 2015; 47: 72–75
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Discussion
75
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Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips
Authors
Takeshi Ogura1, Tatsushi Sano1, Saori Onda1, Akira Imoto1, Daisuke Masuda1, Kazuhiro Yamamoto2, Masayuki Kitano3, Toshihisa Takeuchi1, Takuya Inoue1, Kazuhide Higuchi1
Institutions
1
2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan Department of Radiology, Osaka Medical College, Osaka, Japan 3 Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan 2
submitted 26. May 2014 accepted after revision 4. August 2014
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1378111 Published online: 29.9.2014 Endoscopy 2015; 47: 72–75 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Takeshi Ogura, PhD, MD 2nd Department of Internal Medicine Osaka Medical College 1-1 Daigakuchou, Takatsukishi Osaka 464-8681 Japan Fax: +81-527635233 [email protected]
Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is not normally indicated for an obstructed right intrahepatic bile duct (IHBD). The technical feasibility and clinical efficacy of a novel technique of EUS-BD for right IHBD obstruction were evaluated. A total of 11 patients underwent drainage using either a left or a right biliary access route. The causes of obstructive jaundice were cholangiocarcinoma (n = 6), pancreatic can-
cer (n = 3), gastric cancer (n = 1), and colon cancer (n = 1). After placement of an uncovered metal stent to bridge the obstruction, a hepaticogastrostomy was completed using a covered stent. Mean procedure time was 33.9 ± 10.0 minutes. Technical and functional success were achieved in all patients, and no adverse events occurred. This novel method appears to be safe and effective for right IHBD obstruction.
Introduction
Patients and methods
!
!
Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) has been developed as an alternative technique for cases of failed endoscopic biliary drainage, percutaneous transhepatic biliary drainage, or inaccessible papilla [1, 2]. Generally, this novel method, especially EUS-guided hepaticogastrostomy, has been indicated for extrahepatic bile duct obstruction, or for isolated left intrahepatic bile duct (IHBD) obstruction because only the left IHBD can be punctured to access the IHBD tree using transgastric EUS imaging. Therefore, hepatic hilar obstruction and isolated right IHBD obstruction are not normally indications for EUS-guided hepaticogastrostomy. A recent report described EUS-BD for isolated right IHBD obstruction [3], with antegrade stenting using uncovered metal stents or bypass stenting using fully covered metal stents. However, antegrade stenting carries the risk of bile leakage from the fistula, and bypass stenting may result in branch bile duct occlusion from use of the fully covered metal stent. The aim of the current pilot study was to evaluate the technical feasibility and clinical efficacy of a novel technique of EUS-BD for biliary obstruction involving the right hepatic bile duct.
Patients who were histologically diagnosed as having unresectable carcinoma and obstructive jaundice due to an obstructed right IHBD were included in this study from June 2012 to February 2014. Patients provided written informed consent to all procedures associated with the study.
Ogura Takeshi et al. Endoscopic ultrasound-guided biliary drainage … Endoscopy 2015; 47: 72–75
Protocol for EUS-guided biliary drainage One therapeutic endoscopist (T.O.), who was trained and experienced in both EUS and endoscopic retrograde cholangiopancreatography (ERCP), performed the procedures. All patients were given antibiotics before undergoing procedure. The IHBD was imaged at a frequency of 7.5 MHz using a convex echoendoscope (GFUGT260; Olympus Optical Co. Ltd., Tokyo, Japan) connected to an ultrasound device (SSD5500; Aloka, Tokyo, Japan). This novel technique of EUS-BD was applied using either a left or a right biliary access route.
Left biliary access route
" Fig. 1, ● " Video 1) (● The echoendoscope was advanced into the stomach and the left IHBD was visualized. The left IHBD was then punctured using a 19-G needle (Sono Tip Pro Control 19G; Medi-Globe GmbH, Rosenheim, Germany). After aspiration of bile juice, contrast medium was injected and images of the biliary tree were obtained. Then, a 0.025-
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
72
Case series
73
Fig. 2 Locking stent method. a Uncovered metal stent between the right intrahepatic bile duct and the hepatic parenchyma (arrow). b The delivery system is inserted into the uncovered metal stent (red arrow, end of the uncovered metallic stent; yellow arrow, delivery system of the fully covered metal stent). c An uncovered metal stent is placed from the intestine to the hepatic parenchyma. d A fully covered metal stent is then placed from the proximal end of the uncovered metal stent to the duodenal bulb or stomach.
inch stiff guidewire (VisiGlide; Olympus Medical Systems, Tokyo, Japan) was inserted, and a standard ERCP catheter (MTW Endoskopie, Düsseldorf, Germany) replaced the 19-G needle. An attempt was then made to advance the guidewire into the right " Fig. 1 a). If the guidewire could not be advanced into IHBD (● the right IHBD, it was exchanged for a controllable ERCP cannula in order to negotiate the axis between the right IHBD and the ERCP catheter. Next, the delivery system for the uncovered metal stent was inserted (6-Fr delivery, 1 cm × 6 cm, Zilver 635 Biliary Self-Expanding Stent; Cook Medical, Bloomington, Indiana, USA) " Fig. 1 b). After placement of this stent between the right and (● left IHBDs (bridging method), EUS-guided hepaticogastrostomy was performed from the left intrahepatic bile duct to the stomach using a fully covered self-expandable metal stent (end bare type, Niti-S biliary covered stent; TaeWoong Medical, Seoul, Korea) " Fig. 1 c). (● " Fig. 2, ● " Video 2) Right biliary access route (●
The echoendoscope was advanced into the antrum or duodenal bulb. Using counterclockwise rotation, the right IHBD was visualized. To prevent branch bile duct obstruction or bile leakage, double metal stents (locking stent method) were used, as previously described [4]. After puncturing the right IHBD, the uncovered metal stent (Bile Rush; Piolax Medical Devices Inc., Kanagawa, Japan) was placed to bridge the obstruction of the right system to-
" Fig. 2 a,c). A fully covered wards the right hepatic parenchyma (● metal stent was then placed from the proximal end of the uncov" Fig. 2 b,d). ered metal stent to the duodenal bulb or stomach (●
Results !
● Table 1 shows the patient characteristics. The right biliary ac"
cess method was performed in four patients and the left biliary access was used in seven patients. The causes of obstructive jaundice were cholangiocarcinoma (n = 6), pancreatic cancer (n = 3), gastric cancer (n = 1), and colon cancer (n = 1). The reasons for left biliary access were duodenal obstruction (n = 5) and altered anatomy (n = 2), and the reasons for right biliary access were also duodenal obstruction (n = 1), altered anatomy (n = 1), as well as inability to advance the guidewire to the bile duct (n = 2). Access sites for the right route were the antrum (n = 3) and duodenal bulb (n = 1). For left biliary access, a standard ERCP cannula was successfully used in five patients and a controllable ERCP cannula was used in two patients. The mean procedure time was 33.9 ± 10.0 minutes. Total serum bilirubin was significantly decreased after this procedure (from 8.7 ± 2.7 mg/dL to 1.7 ± 1.0 mg/dL; P < 0.05). Technical success was achieved in all patients. No adverse events occurred during a mean follow-up of 4.1 months. Seven patients died from progressive disease.
Ogura Takeshi et al. Endoscopic ultrasound-guided biliary drainage … Endoscopy 2015; 47: 72–75
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Fig. 1 Bridging method. a Using a controllable endoscopic retrograde cholangiopancreatography cannula, the guidewire is advanced into the right hepatic bile duct. b The uncovered metal stent is placed. c Finally, a metal stent is placed from the left hepatic bile duct to the stomach.
Case series
Table 1
Patient characteristics.
Patient #
Type of
Indication
Obstruction
Age, years
cancer
for EUS-BD
site
Puncture site
Drainage method
Dilation
Proce-
Adverse
Follow-up
of fistula
dure
events,
period, days/
time
Early/
clinical
Late1
course
Sex
#1 78 Female
Pancreatic
Duodenal obstruction
Hepatic hilum
Right IHBD from stomach
Locking stent method
None
27
None/ None
88/Dead
2 76 Male
Bile duct
Altered anatomy
Hepatic hilum
Right IHBD from stomach
Locking stent method
Balloon dilation
32
None/ None
189/Alive
3 67 Male
Bile duct
Could not advance the guidewire to the anterior bile duct under ERCP
Right hepatic bile duct
Anterior bile duct from duodenal bulb
Locking stent method
None
22
None/ None
111/Dead
4 63 Female
Bile duct
Could not advance the guidewire to the posterior bile duct under ERCP
Right hepatic bile duct
Posterior bile duct from stomach
Locking stent method
Diathermic dilator
29
None/ None
147/Alive
5 66 Male
Pancreatic
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
31
None/ None
109/Alive
6 68 Female
Bile duct
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
49
None/ None
77/Dead
7 77 Female
Bile duct
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
25
None/ None
92/Alive
8 60 Female
Colon
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
33
None/ None
129/Dead
9 40 Female
Gastric
Altered anatomy
Hepatic hilum
Left IHBD from stomach
Bridging method using controllable ERCP cannula
Balloon dilation
32
None/ None
144/Dead
10 63 Male
Pancreatic
Altered anatomy
Hepatic hilum
Left IHBD from stomach
Bridging method using controllable ERCP cannula
Balloon dilation
55
None/ None
133/Dead
11 89 Female
Cholangio
Duodenal obstruction
Hepatic hilum
Left IHBD from stomach
Bridging method using standard ERCP cannula
None
38
None/ None
127/Dead
EUS-BD, endoscopic ultrasound-guided biliary drainage; IHBD, intrahepatic bile duct; ERCP, endoscopic retrograde cholangiopancreatography. 1 Early adverse event = within 1 week after the procedure; late adverse event = more than 1 week after the procedure.
Video 1
Online content including The left intrahepatic bile duct is punctured, and contrast medium is video sequences viewable injected. The guidewire is then inser- at: www.thieme-connect.de ted into the bile duct. Using an endoscopic retrograde cholangiopancreatography catheter, the guidewire is advanced into the intestine. The 6-Fr delivery system is successfully inserted without a dilation fistula, and the metal stent is placed above the ampulla of Vater. Finally, endoscopic ultrasound-guided hepaticogastrostomy is performed.
Video 2
Online content including From the duodenal bulb, the right video sequences viewable intrahepatic bile duct is visualized at: www.thieme-connect.de and punctured using a 19-G fineneedle aspiration needle. Contrast medium is injected to visualize the biliary tree. The guidewire is then inserted and advanced into the intestine using an endoscopic retrograde cholangiopancreatography catheter. The uncovered metal stent is then placed between the intestine and the hepatic parenchyma. Next, the delivery system for the fully covered metal stent is inserted into the uncovered metal stent, and the fully covered metal stent is placed for drainage into the duodenum.
Ogura Takeshi et al. Endoscopic ultrasound-guided biliary drainage … Endoscopy 2015; 47: 72–75
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
74
Case series
!
For transduodenal EUS-BD, EUS-guided choledochoduodenostomy is performed, in which the common bile duct is punctured and a stent is placed from the bile duct to the duodenum [5 – 7]. This approach is not indicated for cases of duodenal obstruction caused by tumor invasion or surgically altered anatomy. Transgastric EUS-BD is typically performed by accessing the left biliary system from the stomach with stent placement from the left IHBD to the stomach. In the current study, a novel technique of EUS-BD for right IHBD obstruction was applied. Technical and functional success were achieved in all patients. In addition, no severe adverse events occurred. However, this method has potential complications, such as bile leak, stent migration, and infection. Stent dysfunction may be of particular concern with the right-sided biliary access, due to the sharp angle encountered during stent delivery. Technically, this method has several important features. First, from the left access route, it is sometimes challenging to advance the guidewire into the right IHBD. It was very difficult to advance the guidewire into the right IHBD using a standard ERCP cannula in two patients, because of difficulty in aligning the axis to the right-sided bile duct. This challenge was overcome by using a controllable ERCP cannula. Second, stent selection is important. If a fully covered metal stent is selected in the hepatic hilum or right IHBD, a side branch may be occluded. There is also the possibility that misplacement may occur due to stent shortening. Therefore, the uncovered and laser-cut type metal stent was considered to be the most suitable stent type. In addition, a fine stent gauge and effective delivery system are also needed. Third, placement of only one metal stent, which was placed from the IHBD to the stomach or duodenum, without a fully covered
metal stent may risk bile leakage from a fistula. In addition, if only an uncovered metal stent is placed, reintervention following stent occlusion would sometimes be challenging. If occlusion of the uncovered metal stent were to occur, the presented double stent technique would enable straightforward reintervention through the covered stent. Although the present study has several limitations, such as small sample size, patient selection bias, single operator, and only a single arm, this method appears to be safe and effective for right IHBD obstruction. Validation is required in a prospective clinical trial. Competing interests: None
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