J Hepatobiliary Pancreat Sci (2015) 22:664–668 DOI: 10.1002/jhbp.271
TOPIC
Endoscopic ultrasound-guided biliary drainage of hilar biliary obstruction Do Hyun Park Published online: 15 July 2015 © 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound-guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS-guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized. Keywords Biliary obstruction · Endoscopic retrograde cholangiopancreatography · Endoscopic ultrasound-guided biliary drainage · Endoscopic ultrasound-guided hepaticogastrostomy · Percutaneous transhepatic biliary drainage D. H. Park (✉) Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43 Gil, Songpa-gu, Seoul 138-736, Korea e-mail: [email protected] This study was presented at the Tokyo Conference of Asian Pancreato-biliary Interventional Endoscopist 2014, Tokyo, Japan, June 26–27, 2014.
Introduction To date, there are two approaches to endoscopic ultrasoundguided biliary drainage (EUS-BD) (EUS-guided hepaticogastrostomy (HGS) and EUS-guided choledochoduodenostomy) when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful [1–5]. Furthermore, in patients with high grade hilar stricture or occluded biliary metal stent, EUS-HGS may be an effective alternative to percutaneous transhepatic biliary drainage (PTBD) [1, 5]. However, due to complex multi-step process and lack of dedicated device for EUS-BD, EUS-BD is only performed by an expert endosonographers in a tertiary referral center [3]. Therefore, generalization of EUS-BD to routine clinical practice has been limited.
Indications for EUS-BD for hilar biliary obstruction Traditionally, EUS-HGS has been considered as a major route for EUS-BD for hilar biliary obstruction (HBO). However, EUS-guided hepaticoduodenostomy, hepaticoesophagostomy, or hepaticojejunostomy (e.g. patients with total gastrectomy) can be performed for HBO. Therefore, EUS-guided intrahepatic biliary drainage (EUS-IBD) may be more suitable terminology rather than EUS-HGS. Indicated for EUS-IBD for HBO were patients with proximal bile duct obstruction, surgically altered anatomy such as Roux-en-Y anastomosis after failed ERCP [6]. In patients with an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion, EUS-IBD may also be considered as an alternative to PTBD after failed ERCP [5]. Compared with other EUS-BD techniques such as EUScholedochoduodenostomy or rendezvous, EUS-HGS in EUS-IBD may be more feasible in patients with surgically altered anatomy after failed ERCP, because the traverse of guidewire to duodenum or small bowel in the EUS-guided rendezvous technique is not always successful in terms of
J Hepatobiliary Pancreat Sci (2015) 22:664–668
access; a prolonged procedure time is also required [3]. Furthermore, EUS-HGS can eliminate the need for deep enteroscopy for the grasp of antegrade-placed guidewire into the small bowel in patients with surgically altered anatomy during EUS-HGS with rendezvous technique [6]. Equipment of EUS-IBD for hilar obstruction The equipment for EUS-BD for HBO is shown Table 1. Technique of EUS-IBD Ideal puncture for EUS-HGS is the most important technical issue. As in precutting in ERCP, the puncture of dilated intrahepatic bile duct in EUS-HGS may be a free-hand technique and it may have a learning curve for successful procedure. Most likely, B2 approach can be accessed by the cardia or gastroesophageal junction [1]. B3 approach can be performed via the lesser curve of the stomach body. B2 approach may be more ideal for rendezvous or antegrade stenting because this route may be a relatively straight line to the hilar portion. Rendezvous or antegrade stenting may be more difficult in the B3 approach [5]. However, B3 approach may be more suitable for EUS-HGS with transmural stenting. Rarely, hepaticoesophagostomy can be made in such patients with advanced gastric cancer with pyloric and high body cancer involvement. In patients with total gastrectomy and failed ERCP, EUS-guided hepaticojejunostomy can be performed. In HBO, transmural stenting is performed in most cases because the passage of transhepatically placed guidewire into the duodenum across the hilar biliary stricture is technically challenging [3]. For dilation of the transmural tract, a graded dilation, 4 mm balloon catheter, or 6-Fr cystome can be used as in EUS-guided pseudocyst drainage. Briefly, an ultra-taper to 4-Fr ERCP cannula is inserted over the guidewire. Then, Table 1 Equipment for endoscopic ultrasound-guided intrahepatic biliary drainage (EUS-IBD) Curvilinear EUS 19-gauge EUS FNA needle 0.025 inch guidewire (same stiffness as 0.035 inch guidewire) Transmural stenting 4-Fr ERCP catheter 6-7-Fr bougie dilator Triple lumen needle knife 6-Fr cystotome 4 mm balloon catheter 7-Fr plastic stent (double pig-tail) Fully covered or partially covered metal stent
665
6-Fr and 7-Fr biliary dilator catheters are inserted over the guidewire and removed, in that order, to dilate the tract. If there is resistance to the advancement of the 6-Fr dilator catheter, a triple lumen needle-knife with a 7-Fr shaft diameter or a cystotome is gently inserted over the guidewire to dilate the tract using a brief burst of pure cutting current [1, 5]. Recently, 4 mm balloon dilation as coaxial fistula dilator has been used for reducing the multistep-process of graded dilation or risk of adverse events by needle cautery [7]. A plastic stent, or fully or partially covered expandable metal stent is then transgastrically deployed into the left intrahepatic system [6, 8]. Technical troubleshooting of EUS-HGS The deployment of a stent under fluoroscopic and endoscopic guidance is mandatory, as in stent placement in EUS-guided drainage of pseudocysts. In transgastric stenting through B3, the scope position will be backward for identification of the distal end of the deploying stent, and a stent will eventually be placed in a more inner side of the intrahepatic duct during stent deployment (especially in J-shaped stomach) [1, 9]. This may bring proximal stent migration after stent deployment. Therefore, a longer stent, i.e. 8 or 10 cm in length, is superior for the prevention of this complication [1]. Another technical tip for stent deployment is that the scope should be placed and attached to the gastric wall [1]. Stent deployment should therefore be performed under EUS and fluoroscopic guidance. This may help for reducing accidental proximal or distal migration [1]. If the placed metal stent appears to be relatively short for the transmural tract, another metal stent can be placed in a stent-in-stent manner [1]. In this circumstance, a fully covered self-expandable metal stent (FCSEMS) with adequate length for a bridging between liver parenchyma and gastric wall may be considered. As usual, fully covered or partially covered self expandable metal stents may be considered for EUS-HGS with transmural stenting. During the follow-up period following EUS-HGS, some patients may need a stent revision for various reasons, such as stent clogging. Clinical outcomes on EUS-HGS with transmural stenting Compared with EUS-HGS with rendezvous techniques, EUSHGS may involve a higher chance of adverse events because of its procedural complexity [6]. In EUS-HGS, the technical success rate is 91–100% and the clinical success rate is 75– 100% (Table 2). The overall rate of post-procedure adverse events is 25% [4, 6, 10–16]. Post-procedure adverse event included stent migration, bile leaks, pneumoperitoneum, and cholangitis [6]. Even though complications such as bile
666
J Hepatobiliary Pancreat Sci (2015) 22:664–668
Table 2 Technical and clinical success and rates, adverse event rates in published cases with endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) Study
No. patients
Technical success (%)
Clinical success (%)
Procedural adverse event (%)
Burmester et al. [11] Kahaleh et al. [12] Will et al. [14] Bories et al. [10] Artifon et al. [16] Ramirez-Luna et al. [24] Park et al. [6] Park et al. [3] Total
1 2 4 11 1 2 31 15 67
1/1 (100) 2/2 (100) 4/4 (100) 10/11 (91) 1/1 (100) 2/2 (100) 31/31 (100) 14/15 (93) 65/67 (97)
1/1 (100) 2/2 (100) 3/4 (75) 10/10 (100) 1/1 (100) 2/2 (100) 27/31 (87) 14/15 (93) 60/67 (89)
0 0 1/4 (25) 4/11 (36.4) 0 1/2 (50) 6/31 (19) 2*/15 (13) 15/67 (22)
Profiles of post-procedure adverse event
Cholangitis Ileus, biloma, stent migration, and cholangitis in each case Distal stent migration Self-limited pneumoperitoneum (4), mild bleeding (2) Biloma (1), intraperitoneal stent migration (1)
* One patient had biloma and intraperitoneal stent migration
peritonitis or pneumoperitoneum occur during or after placement of FCSEMS, EUS-BD with transluminal stenting (EUS-BDS) with an FCSEMS may prevent further grades of such complications, because the dilated fistulous tract can be immediately sealed using an FCSEMS [4, 6]. However, proximal stent migration to the liver is possible if the distal end of the stent in the stomach is not adequate. In this complication, delayed bile peritonitis may develop [17]. Therefore, adequate distal end of the stent in the stomach (at least 1.5 cm) should be secured. Recently, hybrid metal stent with partially uncovered metal stent (1.5 to 5.5 cm) in proximal portion and anchoring flaps has been introduced for the prevention of proximal or distal stent migration, and stent-induced cholangitis or cholecystitis in EUS-BD [18]. Delayed stent migration and stent-induced cholangitis or cholecystitis can be prevented by this type of stent design. However, further larger studies may be required to determine whether immediate stent migration such as intraperitoneal stent migration or bile leak from uncovered stent portion can be prevented by this type of stent design. In a recent prospective follow-up study [6], EUS-HGS had similar technical and functional success compared with EUS-guided choledochoduodenostomy. Both techniques offer durable and comparable stent patency. However, further multicenter studies comparing EUS-HGS and choledochoduodenostomy may be required to confirm this result. New concept and technology for EUS-BD of hilar obstruction In right-sided intrahepatic biliary obstruction or complex hilar biliary strictures such as Klatskin tumor Bismuth type III or IV, EUS-HGS may not be effective for these circumstances because EUS-HGS is a left-sided biliary decompression [8]. For this situation, EUS-guided hepaticoduodenostomy has been tried. Park et al. first described the EUS-guided
hepaticoduodenostomy for isolated intrahepatic duct obstruction [19]. In six patients with isolated right intrahepatic obstruction, EUS-guided hepaticoduodenostomy with roadmap, antegrade stenting, or bypass stenting was successful in five patients [19]. Because this approach is performed on the lateral side of duodenal bulb or proximal second duodenum, long endoscope position seems to be unstable (Fig. 1). Therefore, this procedure should be limited to highly selective patients and performed by experienced interventional endoscopists. Recently, Ogura et al. described technical tips for EUS-BD for right bile duct obstruction [20]. In the bridging method, using a controllable ERCP catheter, the guidewire is advanced into the right hepatic bile duct. After uncovering the metal stent placed between the right hepatic obstruction and hilum, another metal stent is placed from the left hepatic bile duct to the stomach. In the locking stent method, an uncovered metal stent is placed between the right intrahepatic bile duct and the hepatic parenchyma. The delivery system of a fully covered metal stent is inserted into the uncovered metal stent. A fully covered metal stent is then placed from the proximal end of the uncovered metal stent to the duodenal bulb or stomach [20]. Endoscopic transpapillary bilateral metal stenting may be one of the treatments for complex HBO. After successful stenting, stent revision due to stent clogging, tumor ingrowth or overgrowth through mesh of uncovered metal stent is not uncommon. For this circumstance, additional PTBD or EUS-HGS may be required because transpapillary stent revision through complicated wire mesh in the hilar portion may be difficult. Therefore, theoretically, simultaneous left-sided EUS-HGS and right-sided transpapillary bilateral stenting may provide a possible chance of longer stent patency with less event of stent clogging (Fig. 2). However, due to technical difficulty and the unpopularity of EUS-HGS and the cost of multiple stentings, further clinical trials with highly selected patients such as B–III or IV patients without liver atophy may be required.
J Hepatobiliary Pancreat Sci (2015) 22:664–668
(a)
667
(b)
(d)
(c)
(e)
Fig. 1 Endoscopic ultrasound (EUS)-guided hepaticoduodenostomy. (a) After failed endoscopic retrograde cholangiopancreatography (ERCP), EUSguided hepaticoduodenstomy was performed in patients with right intrahepatic obstruction. On EUS, the right posterior intrahepatic duct was punctured by a 19-gauge EUS needle (right upper inset). (b) Fistula track was dilated by 4 mm balloon catheter. (c, d, e) a fully covered metal stent with anchoring flaps was placed through hepaticoduodenostomy. This fistula site was located on the lateral portion of the proximal second duodenum. Finally, a nasocystic drainage tube was placed through a fully covered metal stent
Fig. 2 Concept of combined endoscopic ultrasound (EUS)-guided hepaticogastrostomy for left-sided bile duct obstruction and transpapillary bilateral stenting for right-sided bile duct obstruction in patients with B-III or IV hilar obstruction
In various benign and malignant conditions, such as intrahepatic ductal stones, anastomotic biliary strictures, or hilar biliary strictures, previous case series suggest the route of
EUS-HGS may serve as a conduit for various interventional endoscopic procedures [21, 22]. Therefore, indications for EUS-HGS may be extended after dedicated endoscopic devices for EUS-HGS are launched and the safety and efficacy of this technique validated. In EUS-IBD, there remains a risk of losing access, because only a short length of the guidewire remains coiled within the intrahepatic system during exchange of accessories [8]. Furthermore, the use of a needle-knife for fistula dilation was the risk factor for post-procedure adverse events after EUS-BD in a recent prospective study [6]. Therefore, development of dedicated endoscopic devices for fistula dilation and guidewire manipulation in EUSBD may be warranted. Recently, a newly designed tapered metal tip 7-Fr introducer with preloaded partially covered metal stent for onestep EUS-BDS without additional fistula dilation process has been developed for human clinical trial [23]. The technical feasibility and safety of this device for EUS-BD must be considered. In conclusion, EUS-IBD for HBO may be a promising modality that may represent a potential alternative to PTBD after failed ERCP. However, this procedure should be performed by experienced endosonographers who are trained in ERCP and interventional EUS.
668
J Hepatobiliary Pancreat Sci (2015) 22:664–668
Further technical innovation and refinement of EUS-BD may be warranted for generalization of this procedure to endosonographers with a varied range of experiences with EUS-BD. Conflict of interest
None declared.
References 1. Park do H. Endoscopic ultrasonography-guided hepaticogastrostomy. Gastrointest Endosc Clin N Am. 2012;22:271–80, ix. 2. Park do H, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUSguided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc. 2011;74:1276–84. 3. Park do H, Jeong SU, Lee BU, Lee SS, Seo DW, Lee SK, et al. Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video). Gastrointest Endosc. 2013;78:91–101. 4. Park do H, Koo JE, Oh J, Lee YH, Moon SH, Lee SS, et al. EUSguided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study. Am J Gastroenterol. 2009;104:2168–74. 5. Park do H, Song TJ, Eum J, Moon SH, Lee SS, Seo DW, et al. EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos). Gastrointest Endosc. 2010;71:413–9. 6. Park do H, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUSguided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc. 2011;74:1276–84. 7. Paik WH, Park do H, Choi JH, Lee SS, Seo DW, Lee SK, et al. Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy. World J Gastroenterol. 2014;20:5051–9. 8. Savides TJ, Varadarajulu S, Palazzo L. EUS 2008 Working Group document: evaluation of EUS-guided hepaticogastrostomy. Gastrointest Endosc. 2009;69(2 Suppl):S3–7. 9. Itoi T, Yasuda I, Kurihara T, Itokawa F, Kasuya K. Technique of endoscopic ultrasonography-guided pancreatic duct intervention (with videos). J Hepatobiliary Pancreat Sci. 2014;21:E4–9. 10. Bories E, Pesenti C, Caillol F, Lopes C, Giovannini M. Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study. Endoscopy. 2007;39:287–91.
11. Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUScholangio-drainage of the bile duct: report of 4 cases. Gastrointest Endosc. 2003;57:246–51. 12. Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM, Yeaton P. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc. 2006;64:52–9. 13. Will U, Meyer F, Schmitt W, Dollhopf M. Endoscopic ultrasoundguided transesophageal cholangiodrainage and consecutive endoscopic transhepatic Wallstent insertion into a jejunal stenosis. Scand J Gastroenterol. 2007;42:412–5. 14. Will U, Thieme A, Fueldner F, Gerlach R, Wanzar I, Meyer F. Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage. Endoscopy. 2007;39:292–5. 15. Yamao K, Hara K, Mizuno N, Sawaki A, Hijioka S, Niwa Y, et al. EUS-Guided Biliary Drainage. Gut Liver. 2010;4(Suppl 1):S67–75. 16. Artifon EL, Chaves DM, Ishioka S, Souza TF, Matuguma SE, Sakai P. Echoguided hepatico-gastrostomy: a case report. Clinics (Sao Paulo). 2007;62:799–802. 17. Martins FP, Rossini LG, Ferrari AP. Migration of a covered metallic stent following endoscopic ultrasound-guided hepaticogastrostomy: fatal complication. Endoscopy. 2010;42(Suppl 2):E126–7. 18. Song TJ, Lee SS, Park do H, Seo DW, Lee SK, Kim MH. Preliminary report on a new hybrid metal stent for EUS-guided biliary drainage (with videos). Gastrointest Endosc. 2014;80:707–11. 19. Park SJ, Choi JH, Park do H, Lee SS, Seo DW, Lee SK, et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc. 2013;78:374–80. 20. Ogura T, Sano T, Onda S, Imoto A, Masuda D, Yamamoto K, et al. Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips. Endoscopy. 2015;47:72–5. 21. Eum J, Park do H, Ryu CH, Kim HJ, Lee SS, Seo DW, et al. EUSguided biliary drainage with a fully covered metal stent as a novel route for natural orifice transluminal endoscopic biliary interventions: a pilot study (with videos). Gastrointest Endosc. 2010;72:1279–84. 22. Park DH, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUSguided transhepatic antegrade balloon dilation for benign bilioenteric anastomotic strictures in a patient with hepaticojejunostomy. Gastrointest Endosc. 2012;75:692–3. 23. Lee TH, Choi JH, Lee SS, Cho HD, Seo DW, Park SH, et al. A pilot proof-of-concept study of a modified device for one-step endoscopic ultrasound-guided biliary drainage in a new experimental biliary dilatation animal model. World J Gastroenterol. 2014;20:5859–66. 24. Ramirez-Luna MA, Tellez-Avila FI, Giovannini M, ValdovinosAndraca F, Guerrero-Hernandez I, Herrera-Esquivel J. Endoscopic ultrasound-guided biliodigestive drainage is a good alternative in patients with unresectable cancer. Endoscopy. 2011;43:826–30.
TOPIC
Endoscopic ultrasound-guided biliary drainage of hilar biliary obstruction Do Hyun Park Published online: 15 July 2015 © 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound-guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS-guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized. Keywords Biliary obstruction · Endoscopic retrograde cholangiopancreatography · Endoscopic ultrasound-guided biliary drainage · Endoscopic ultrasound-guided hepaticogastrostomy · Percutaneous transhepatic biliary drainage D. H. Park (✉) Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43 Gil, Songpa-gu, Seoul 138-736, Korea e-mail: [email protected] This study was presented at the Tokyo Conference of Asian Pancreato-biliary Interventional Endoscopist 2014, Tokyo, Japan, June 26–27, 2014.
Introduction To date, there are two approaches to endoscopic ultrasoundguided biliary drainage (EUS-BD) (EUS-guided hepaticogastrostomy (HGS) and EUS-guided choledochoduodenostomy) when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful [1–5]. Furthermore, in patients with high grade hilar stricture or occluded biliary metal stent, EUS-HGS may be an effective alternative to percutaneous transhepatic biliary drainage (PTBD) [1, 5]. However, due to complex multi-step process and lack of dedicated device for EUS-BD, EUS-BD is only performed by an expert endosonographers in a tertiary referral center [3]. Therefore, generalization of EUS-BD to routine clinical practice has been limited.
Indications for EUS-BD for hilar biliary obstruction Traditionally, EUS-HGS has been considered as a major route for EUS-BD for hilar biliary obstruction (HBO). However, EUS-guided hepaticoduodenostomy, hepaticoesophagostomy, or hepaticojejunostomy (e.g. patients with total gastrectomy) can be performed for HBO. Therefore, EUS-guided intrahepatic biliary drainage (EUS-IBD) may be more suitable terminology rather than EUS-HGS. Indicated for EUS-IBD for HBO were patients with proximal bile duct obstruction, surgically altered anatomy such as Roux-en-Y anastomosis after failed ERCP [6]. In patients with an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion, EUS-IBD may also be considered as an alternative to PTBD after failed ERCP [5]. Compared with other EUS-BD techniques such as EUScholedochoduodenostomy or rendezvous, EUS-HGS in EUS-IBD may be more feasible in patients with surgically altered anatomy after failed ERCP, because the traverse of guidewire to duodenum or small bowel in the EUS-guided rendezvous technique is not always successful in terms of
J Hepatobiliary Pancreat Sci (2015) 22:664–668
access; a prolonged procedure time is also required [3]. Furthermore, EUS-HGS can eliminate the need for deep enteroscopy for the grasp of antegrade-placed guidewire into the small bowel in patients with surgically altered anatomy during EUS-HGS with rendezvous technique [6]. Equipment of EUS-IBD for hilar obstruction The equipment for EUS-BD for HBO is shown Table 1. Technique of EUS-IBD Ideal puncture for EUS-HGS is the most important technical issue. As in precutting in ERCP, the puncture of dilated intrahepatic bile duct in EUS-HGS may be a free-hand technique and it may have a learning curve for successful procedure. Most likely, B2 approach can be accessed by the cardia or gastroesophageal junction [1]. B3 approach can be performed via the lesser curve of the stomach body. B2 approach may be more ideal for rendezvous or antegrade stenting because this route may be a relatively straight line to the hilar portion. Rendezvous or antegrade stenting may be more difficult in the B3 approach [5]. However, B3 approach may be more suitable for EUS-HGS with transmural stenting. Rarely, hepaticoesophagostomy can be made in such patients with advanced gastric cancer with pyloric and high body cancer involvement. In patients with total gastrectomy and failed ERCP, EUS-guided hepaticojejunostomy can be performed. In HBO, transmural stenting is performed in most cases because the passage of transhepatically placed guidewire into the duodenum across the hilar biliary stricture is technically challenging [3]. For dilation of the transmural tract, a graded dilation, 4 mm balloon catheter, or 6-Fr cystome can be used as in EUS-guided pseudocyst drainage. Briefly, an ultra-taper to 4-Fr ERCP cannula is inserted over the guidewire. Then, Table 1 Equipment for endoscopic ultrasound-guided intrahepatic biliary drainage (EUS-IBD) Curvilinear EUS 19-gauge EUS FNA needle 0.025 inch guidewire (same stiffness as 0.035 inch guidewire) Transmural stenting 4-Fr ERCP catheter 6-7-Fr bougie dilator Triple lumen needle knife 6-Fr cystotome 4 mm balloon catheter 7-Fr plastic stent (double pig-tail) Fully covered or partially covered metal stent
665
6-Fr and 7-Fr biliary dilator catheters are inserted over the guidewire and removed, in that order, to dilate the tract. If there is resistance to the advancement of the 6-Fr dilator catheter, a triple lumen needle-knife with a 7-Fr shaft diameter or a cystotome is gently inserted over the guidewire to dilate the tract using a brief burst of pure cutting current [1, 5]. Recently, 4 mm balloon dilation as coaxial fistula dilator has been used for reducing the multistep-process of graded dilation or risk of adverse events by needle cautery [7]. A plastic stent, or fully or partially covered expandable metal stent is then transgastrically deployed into the left intrahepatic system [6, 8]. Technical troubleshooting of EUS-HGS The deployment of a stent under fluoroscopic and endoscopic guidance is mandatory, as in stent placement in EUS-guided drainage of pseudocysts. In transgastric stenting through B3, the scope position will be backward for identification of the distal end of the deploying stent, and a stent will eventually be placed in a more inner side of the intrahepatic duct during stent deployment (especially in J-shaped stomach) [1, 9]. This may bring proximal stent migration after stent deployment. Therefore, a longer stent, i.e. 8 or 10 cm in length, is superior for the prevention of this complication [1]. Another technical tip for stent deployment is that the scope should be placed and attached to the gastric wall [1]. Stent deployment should therefore be performed under EUS and fluoroscopic guidance. This may help for reducing accidental proximal or distal migration [1]. If the placed metal stent appears to be relatively short for the transmural tract, another metal stent can be placed in a stent-in-stent manner [1]. In this circumstance, a fully covered self-expandable metal stent (FCSEMS) with adequate length for a bridging between liver parenchyma and gastric wall may be considered. As usual, fully covered or partially covered self expandable metal stents may be considered for EUS-HGS with transmural stenting. During the follow-up period following EUS-HGS, some patients may need a stent revision for various reasons, such as stent clogging. Clinical outcomes on EUS-HGS with transmural stenting Compared with EUS-HGS with rendezvous techniques, EUSHGS may involve a higher chance of adverse events because of its procedural complexity [6]. In EUS-HGS, the technical success rate is 91–100% and the clinical success rate is 75– 100% (Table 2). The overall rate of post-procedure adverse events is 25% [4, 6, 10–16]. Post-procedure adverse event included stent migration, bile leaks, pneumoperitoneum, and cholangitis [6]. Even though complications such as bile
666
J Hepatobiliary Pancreat Sci (2015) 22:664–668
Table 2 Technical and clinical success and rates, adverse event rates in published cases with endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) Study
No. patients
Technical success (%)
Clinical success (%)
Procedural adverse event (%)
Burmester et al. [11] Kahaleh et al. [12] Will et al. [14] Bories et al. [10] Artifon et al. [16] Ramirez-Luna et al. [24] Park et al. [6] Park et al. [3] Total
1 2 4 11 1 2 31 15 67
1/1 (100) 2/2 (100) 4/4 (100) 10/11 (91) 1/1 (100) 2/2 (100) 31/31 (100) 14/15 (93) 65/67 (97)
1/1 (100) 2/2 (100) 3/4 (75) 10/10 (100) 1/1 (100) 2/2 (100) 27/31 (87) 14/15 (93) 60/67 (89)
0 0 1/4 (25) 4/11 (36.4) 0 1/2 (50) 6/31 (19) 2*/15 (13) 15/67 (22)
Profiles of post-procedure adverse event
Cholangitis Ileus, biloma, stent migration, and cholangitis in each case Distal stent migration Self-limited pneumoperitoneum (4), mild bleeding (2) Biloma (1), intraperitoneal stent migration (1)
* One patient had biloma and intraperitoneal stent migration
peritonitis or pneumoperitoneum occur during or after placement of FCSEMS, EUS-BD with transluminal stenting (EUS-BDS) with an FCSEMS may prevent further grades of such complications, because the dilated fistulous tract can be immediately sealed using an FCSEMS [4, 6]. However, proximal stent migration to the liver is possible if the distal end of the stent in the stomach is not adequate. In this complication, delayed bile peritonitis may develop [17]. Therefore, adequate distal end of the stent in the stomach (at least 1.5 cm) should be secured. Recently, hybrid metal stent with partially uncovered metal stent (1.5 to 5.5 cm) in proximal portion and anchoring flaps has been introduced for the prevention of proximal or distal stent migration, and stent-induced cholangitis or cholecystitis in EUS-BD [18]. Delayed stent migration and stent-induced cholangitis or cholecystitis can be prevented by this type of stent design. However, further larger studies may be required to determine whether immediate stent migration such as intraperitoneal stent migration or bile leak from uncovered stent portion can be prevented by this type of stent design. In a recent prospective follow-up study [6], EUS-HGS had similar technical and functional success compared with EUS-guided choledochoduodenostomy. Both techniques offer durable and comparable stent patency. However, further multicenter studies comparing EUS-HGS and choledochoduodenostomy may be required to confirm this result. New concept and technology for EUS-BD of hilar obstruction In right-sided intrahepatic biliary obstruction or complex hilar biliary strictures such as Klatskin tumor Bismuth type III or IV, EUS-HGS may not be effective for these circumstances because EUS-HGS is a left-sided biliary decompression [8]. For this situation, EUS-guided hepaticoduodenostomy has been tried. Park et al. first described the EUS-guided
hepaticoduodenostomy for isolated intrahepatic duct obstruction [19]. In six patients with isolated right intrahepatic obstruction, EUS-guided hepaticoduodenostomy with roadmap, antegrade stenting, or bypass stenting was successful in five patients [19]. Because this approach is performed on the lateral side of duodenal bulb or proximal second duodenum, long endoscope position seems to be unstable (Fig. 1). Therefore, this procedure should be limited to highly selective patients and performed by experienced interventional endoscopists. Recently, Ogura et al. described technical tips for EUS-BD for right bile duct obstruction [20]. In the bridging method, using a controllable ERCP catheter, the guidewire is advanced into the right hepatic bile duct. After uncovering the metal stent placed between the right hepatic obstruction and hilum, another metal stent is placed from the left hepatic bile duct to the stomach. In the locking stent method, an uncovered metal stent is placed between the right intrahepatic bile duct and the hepatic parenchyma. The delivery system of a fully covered metal stent is inserted into the uncovered metal stent. A fully covered metal stent is then placed from the proximal end of the uncovered metal stent to the duodenal bulb or stomach [20]. Endoscopic transpapillary bilateral metal stenting may be one of the treatments for complex HBO. After successful stenting, stent revision due to stent clogging, tumor ingrowth or overgrowth through mesh of uncovered metal stent is not uncommon. For this circumstance, additional PTBD or EUS-HGS may be required because transpapillary stent revision through complicated wire mesh in the hilar portion may be difficult. Therefore, theoretically, simultaneous left-sided EUS-HGS and right-sided transpapillary bilateral stenting may provide a possible chance of longer stent patency with less event of stent clogging (Fig. 2). However, due to technical difficulty and the unpopularity of EUS-HGS and the cost of multiple stentings, further clinical trials with highly selected patients such as B–III or IV patients without liver atophy may be required.
J Hepatobiliary Pancreat Sci (2015) 22:664–668
(a)
667
(b)
(d)
(c)
(e)
Fig. 1 Endoscopic ultrasound (EUS)-guided hepaticoduodenostomy. (a) After failed endoscopic retrograde cholangiopancreatography (ERCP), EUSguided hepaticoduodenstomy was performed in patients with right intrahepatic obstruction. On EUS, the right posterior intrahepatic duct was punctured by a 19-gauge EUS needle (right upper inset). (b) Fistula track was dilated by 4 mm balloon catheter. (c, d, e) a fully covered metal stent with anchoring flaps was placed through hepaticoduodenostomy. This fistula site was located on the lateral portion of the proximal second duodenum. Finally, a nasocystic drainage tube was placed through a fully covered metal stent
Fig. 2 Concept of combined endoscopic ultrasound (EUS)-guided hepaticogastrostomy for left-sided bile duct obstruction and transpapillary bilateral stenting for right-sided bile duct obstruction in patients with B-III or IV hilar obstruction
In various benign and malignant conditions, such as intrahepatic ductal stones, anastomotic biliary strictures, or hilar biliary strictures, previous case series suggest the route of
EUS-HGS may serve as a conduit for various interventional endoscopic procedures [21, 22]. Therefore, indications for EUS-HGS may be extended after dedicated endoscopic devices for EUS-HGS are launched and the safety and efficacy of this technique validated. In EUS-IBD, there remains a risk of losing access, because only a short length of the guidewire remains coiled within the intrahepatic system during exchange of accessories [8]. Furthermore, the use of a needle-knife for fistula dilation was the risk factor for post-procedure adverse events after EUS-BD in a recent prospective study [6]. Therefore, development of dedicated endoscopic devices for fistula dilation and guidewire manipulation in EUSBD may be warranted. Recently, a newly designed tapered metal tip 7-Fr introducer with preloaded partially covered metal stent for onestep EUS-BDS without additional fistula dilation process has been developed for human clinical trial [23]. The technical feasibility and safety of this device for EUS-BD must be considered. In conclusion, EUS-IBD for HBO may be a promising modality that may represent a potential alternative to PTBD after failed ERCP. However, this procedure should be performed by experienced endosonographers who are trained in ERCP and interventional EUS.
668
J Hepatobiliary Pancreat Sci (2015) 22:664–668
Further technical innovation and refinement of EUS-BD may be warranted for generalization of this procedure to endosonographers with a varied range of experiences with EUS-BD. Conflict of interest
None declared.
References 1. Park do H. Endoscopic ultrasonography-guided hepaticogastrostomy. Gastrointest Endosc Clin N Am. 2012;22:271–80, ix. 2. Park do H, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUSguided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc. 2011;74:1276–84. 3. Park do H, Jeong SU, Lee BU, Lee SS, Seo DW, Lee SK, et al. Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video). Gastrointest Endosc. 2013;78:91–101. 4. Park do H, Koo JE, Oh J, Lee YH, Moon SH, Lee SS, et al. EUSguided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study. Am J Gastroenterol. 2009;104:2168–74. 5. Park do H, Song TJ, Eum J, Moon SH, Lee SS, Seo DW, et al. EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos). Gastrointest Endosc. 2010;71:413–9. 6. Park do H, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUSguided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc. 2011;74:1276–84. 7. Paik WH, Park do H, Choi JH, Lee SS, Seo DW, Lee SK, et al. Simplified fistula dilation technique and modified stent deployment maneuver for EUS-guided hepaticogastrostomy. World J Gastroenterol. 2014;20:5051–9. 8. Savides TJ, Varadarajulu S, Palazzo L. EUS 2008 Working Group document: evaluation of EUS-guided hepaticogastrostomy. Gastrointest Endosc. 2009;69(2 Suppl):S3–7. 9. Itoi T, Yasuda I, Kurihara T, Itokawa F, Kasuya K. Technique of endoscopic ultrasonography-guided pancreatic duct intervention (with videos). J Hepatobiliary Pancreat Sci. 2014;21:E4–9. 10. Bories E, Pesenti C, Caillol F, Lopes C, Giovannini M. Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study. Endoscopy. 2007;39:287–91.
11. Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUScholangio-drainage of the bile duct: report of 4 cases. Gastrointest Endosc. 2003;57:246–51. 12. Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM, Yeaton P. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc. 2006;64:52–9. 13. Will U, Meyer F, Schmitt W, Dollhopf M. Endoscopic ultrasoundguided transesophageal cholangiodrainage and consecutive endoscopic transhepatic Wallstent insertion into a jejunal stenosis. Scand J Gastroenterol. 2007;42:412–5. 14. Will U, Thieme A, Fueldner F, Gerlach R, Wanzar I, Meyer F. Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage. Endoscopy. 2007;39:292–5. 15. Yamao K, Hara K, Mizuno N, Sawaki A, Hijioka S, Niwa Y, et al. EUS-Guided Biliary Drainage. Gut Liver. 2010;4(Suppl 1):S67–75. 16. Artifon EL, Chaves DM, Ishioka S, Souza TF, Matuguma SE, Sakai P. Echoguided hepatico-gastrostomy: a case report. Clinics (Sao Paulo). 2007;62:799–802. 17. Martins FP, Rossini LG, Ferrari AP. Migration of a covered metallic stent following endoscopic ultrasound-guided hepaticogastrostomy: fatal complication. Endoscopy. 2010;42(Suppl 2):E126–7. 18. Song TJ, Lee SS, Park do H, Seo DW, Lee SK, Kim MH. Preliminary report on a new hybrid metal stent for EUS-guided biliary drainage (with videos). Gastrointest Endosc. 2014;80:707–11. 19. Park SJ, Choi JH, Park do H, Lee SS, Seo DW, Lee SK, et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc. 2013;78:374–80. 20. Ogura T, Sano T, Onda S, Imoto A, Masuda D, Yamamoto K, et al. Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips. Endoscopy. 2015;47:72–5. 21. Eum J, Park do H, Ryu CH, Kim HJ, Lee SS, Seo DW, et al. EUSguided biliary drainage with a fully covered metal stent as a novel route for natural orifice transluminal endoscopic biliary interventions: a pilot study (with videos). Gastrointest Endosc. 2010;72:1279–84. 22. Park DH, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUSguided transhepatic antegrade balloon dilation for benign bilioenteric anastomotic strictures in a patient with hepaticojejunostomy. Gastrointest Endosc. 2012;75:692–3. 23. Lee TH, Choi JH, Lee SS, Cho HD, Seo DW, Park SH, et al. A pilot proof-of-concept study of a modified device for one-step endoscopic ultrasound-guided biliary drainage in a new experimental biliary dilatation animal model. World J Gastroenterol. 2014;20:5859–66. 24. Ramirez-Luna MA, Tellez-Avila FI, Giovannini M, ValdovinosAndraca F, Guerrero-Hernandez I, Herrera-Esquivel J. Endoscopic ultrasound-guided biliodigestive drainage is a good alternative in patients with unresectable cancer. Endoscopy. 2011;43:826–30.
