EUS-guided transhepatic cholangiography: report of 6 cases

BACKGROUND: This report describes a novel application of EUS-guided cholangiography in which a transhepatic approach was used to alleviate perihilar and distal biliary obstructions when this could not be accomplished at ERCP. METHODS: EUS-guided transhepatic cholangiography was used to alleviate symptoms of biliary obstruction in 6 patients. In 4 cases, after transgastric puncture of an intrahepatic branch of the obstructed bile duct with a 19- or a 22-gauge EUS needle, a guidewire was advanced antegrade across both the biliary stricture and the papilla. Subsequently, a rendezvous procedure was performed, allowing ERCP and stent placement. OBSERVATIONS: EUS-guided transhepatic cholangiography was performed in 6 patients, with successful rendezvous ERCP and stent placement in 4, and transduodenal stent placement in another patient. Stent placement was unsuccessful in one patient, because of the inability to advance a guidewire into the common hepatic duct. There was no immediate complication of the procedures. CONCLUSIONS: EUS-guided transhepatic cholangiography can be used to access and to drain bile ducts that are obstructed by proximal, as well as distal lesions when ERCP is unsuccessful.     

Interventional EUS cholangiography: A report of five cases

BACKGROUND: ERCP may be unsuccessful because of the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic cholangiography is a classic technique for accessing the bile duct and remains the primary alternative when biliary ERCP is unsuccessful. With the evolution of interventional EUS, additional options are available for management of biliary obstruction. METHODS: EUS cholangiography was performed, after which the puncture was enlarged to form an enterocholedochal fistula that was used for interventions that resulted in biliary decompression in 5 patients with obstructive jaundice. OBSERVATIONS: Cholangiography was readily performed in all 5 patients. In one patient, a guidewire could not be manipulated across the papilla via the enterocholedochal fistula, necessitating percutaneous intervention. Biliary decompression was achieved in the other 4 patients, in the last two, as a single procedure. CONCLUSIONS: Interventional EUS cholangiography is a new technique that allows drainage of a dilated biliary system when the bile duct is inaccessible by conventional ERCP.     

Reality named endoscopic ultrasound biliary drainage

Endoscopic ultrasound (EUS) is used for diagnosis and evaluation of many diseases of the gastrointestinal (GI) tract. In the past, it was used to guide a cholangiography, but nowadays it emerges as a powerful therapeutic tool in biliary drainage. The aims of this review are: outline the rationale for endoscopic ultrasound-guided biliary drainage (EGBD); detail the procedural technique; evaluate the clinical outcomes and limitations of the method; and provide recommendations for the practicing clinician. In cases of failed endoscopic retrograde cholangiopancreatography (ERCP), patients are usually referred for either percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Both these procedures have high rates of undesirable complications. EGBD is an attractive alternative to PTBD or surgery when ERCP fails. EGBD can be performed at two locations: transhepatic or extrahepatic, and the stent can be inserted in an antegrade or retrograde fashion. The drainage route can be transluminal, duodenal or transpapillary, which, again, can be antegrade or retrograde [rendezvous (EUS-RV)]. Complications of all techniques combined include pneumoperitoneum, bleeding, bile leak/peritonitis and cholangitis. We recommend EGBD when bile duct access is not possible because of failed cannulation, altered upper GI tract anatomy, gastric outlet obstruction, a distorted ampulla or a periampullary diverticulum, as a minimally invasive alternative to surgery or radiology.     

Advances in Endoscopic Ultrasound-Guided Biliary Drainage: A Comprehensive Review

Endoscopic retrograde cholangiopancreatography (ERCP) has become the first-line therapy for bile duct drainage. In the hands of experienced endoscopists, conventional ERCP results in a failed cannulation rate of 3% to 5%. This failure can occur more commonly in the setting of altered anatomy or technically difficult cases due to either duodenal or biliary obstruction. In cases of ERCP failure, patients have traditionally been referred for either percutaneous transhepatic biliary drainage (PTBD) or surgery. However, both PTBD and surgery have higher than desirable complication rates. Within the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an attractive alternative to PTBD after failed ERCP. Many groups have reported on the feasibility, efficacy and safety of this technique. This article reviews the indications for ERCP and the currently practiced EUS-BD techniques, including EUS-guided rendezvous, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy.     

Stent implantation through rendezvous technique of PTBD and ERCP: the treatment of obstructive jaundice

OBJECTIVE: To study the technical method and clinical value of stent implantation through the rendezvous technique of percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice. METHODS: Thirty-six patients with obstructive jaundice underwent the rendezvous technique of PTBD and ERCP after initially unsuccessful ERCP. RESULTS: The procedure of 36 cases were all successful. Sixteen cases underwent PTBD drainage from the bile duct through the right lobe approach and in 20 cases the left lobe approach was used. The one-stage procedure involved in the rendezvous technique of PTBD and ERCP was successful in 23 cases, while the other 13 cases underwent PTBD first and then rendezvous ERCP the next time. The serum total bilirubin 4 days later had decreased by 44.75%, and direct bilirubin had decreased by 45.61%. The main complication was infection of the bile duct. CONCLUSION: Stent implantation using the rendezvous technique of PTBD and ERCP is a new and feasible method to treat obstructive jaundice after initially unsuccessful ERCP. This may be of considerable value in clinical practice.     

Multidetector computed tomography cholangiography with multiplanar reformation for the assessment of patients with biliary obstruction

BACKGROUND: We sought to evaluate the diagnostic use of multidetector computed tomography (MDCT) cholangiography with multiplanar reformation (MPR) for the assessment of patients with biliary obstruction. METHODS: MDCT cholangiography with the MPR technique was performed in 58 patients who were thought to have biliary obstruction. No cholangiographic contrast agent was administered. MRCP in 24 patients, Endoscopic retrograde cholangiopancreatography (ERCP) in 46 patients and percutaneous transhepatic cholangiography (PTC) in 24 patients were performed. Eighteen patients underwent biopsy or surgery. The findings on MDCT cholangiography were compared with those of MRCP, ERCP, PTC, biopsy or surgery. RESULTS: The findings of MDCT cholangiography were as follows: choledocholithiasis (n = 34, 56.7%), malignant stricture (n = 14, 23.3%), benign stricture (n = 1, 1.7%), and cholelithiasis (n = 11, 18.3%). A small common bile duct (CBD) stone in one patient could not be detected on MDCT cholangiography. One patient with a small stone in distal CBD detected on MDCT cholangiography had no stone on ERCP. Two patients with initial diagnoses of CBD stones by MDCT cholangiography were disclosed to have malignant bile duct stricture by reference examination. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stones were 96.9% and 96.2%, respectively. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stricture were 85.7% and 100%, respectively. The overall accuracy of MDCT cholangiography for the diagnoses of the causes of biliary obstruction was 89.8%. CONCLUSION: MDCT cholangiography with the MPR technique is a fast and non-invasive technique with relatively high sensitivity and specificity for the diagnoses of the causes of biliary obstruction.     

Prospective assessment of magnetic resonance cholangiopancreatography for noninvasive imaging of the biliary tree.

BACKGROUND: Traditionally, ERCP has been the only reliable method for imaging the biliary tree, but it is invasive and carries a risk of complications. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method for imaging the biliary tree. The aim of this study was to prospectively assess the accuracy of MRCP in a large number of patients. METHODS: Consecutive patients referred to a teaching hospital for ERCP were eligible for study entry. MRCP was performed within 24 hours before ERCP. MRCP findings were compared with ERCP findings or, when the initial ERCP was unsuccessful, with results of repeat ERCP, percutaneous transhepatic cholangiography, or surgery. RESULTS: One hundred forty-six patients underwent 149 ERCP/MRCP procedures, of which 129 were evaluable with successful MRCP and ERCP or an ERCP-equivalent study. Diagnoses included choledocholithiasis in 46 and biliary stricture in 12 patients. The sensitivity, specificity, positive, and negative predictive values for MRCP in the diagnosis of choledocholithiasis were 97.9%, 89.0%, 83.6%, and 98.6%, respectively. All 12 strictures were diagnosed by MRCP (sensitivity 100%, specificity 99.1%). CONCLUSIONS: MRCP is an accurate, noninvasive alternative to ERCP for imaging the biliary tree. Choledocholithiasis and biliary strictures can be reliably diagnosed or excluded by MRCP. MRCP should be used increasingly in patients with suspected biliary obstruction to select those who require a therapeutic procedure.     

Prospective comparison of transcutaneous 3-dimensional US cholangiography, magnetic resonance cholangiography, and direct cholangiography in the evaluation of malignant biliary obstruction

BACKGROUND: The purpose of this study was to investigate the ability of transcutaneous three-dimensional US cholangiography to depict the biliary tree in malignant obstruction, compared with that of MRCP and direct cholangiography. METHODS: Three-dimensional US and MRCP and direct cholangiography were performed in 40 patients with suspected malignant biliary obstruction. Diagnostic quality of the images, presence, level, and cause of ductal obstruction were assessed in a prospective, blinded fashion. The results were correlated with consensus interpretation (3 investigators), intra-operative findings, and histopathology or clinical follow-up. RESULTS: Three-dimensional US produced cholangiographic images of diagnostic quality. The appearance of these images was similar to that of MRCP or ERCP/percutaneous transhepatic cholangiography images. All modalities were highly sensitive in the detection of biliary dilatation. The accuracy of 3-dimensional US, MRCP, and ERCP/percutaneous transhepatic cholangiography in determining the level of obstruction was, respectively, 92%, 95%, and 98%. Transcutaneous 3-dimensional US and MRCP accurately identified the cause of obstruction in, respectively, 90% and 95% of cases. Direct cholangiography revealed the correct diagnosis in 95% of the patients. CONCLUSIONS: Three-dimensional US cholangiography is a new, noninvasive method with the capability to produce diagnostic cholangiograms. Three-dimensional US cholangiography may be used increasingly as an initial test to select patients who require further diagnostic evaluation by MRCP or therapeutic ERCP.     

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY

Endoscopic biliary drainage (EBD) may be unsuccessful in some patients, because of failed biliary cannulation or tumor infiltration, limiting endoscopic access to major papilla. The alternative method of percutaneous transhepatic biliary drainage carries a risk of complications, such as bleeding, portal vein thrombus, portal vein occlusion and intra‐ or extra‐abdominal bile leakage. Recently, endoscopic ultrasonography (EUS)‐guided biliary stent placement has been described in patients with malignant biliary obstruction. Technically, EUS‐guided biliary drainage is possible via transgastric or transduodenal routes or through the small intestine using a direct access or rendezvous technique. We describe herein a technique for direct stent insertion from the duodenal bulb for the management of patients with jaundice caused by malignant obstruction of the lower extrahepatic bile duct. We think transduodenal direct access is the best treatment in patients with jaundice caused by inoperable malignant obstruction of the lower extrahepatic bile duct when EBD fails.     

Acute bacterial cholangitis

Opinion statement Acute bacterial cholangitis refers to a bacterial infection of the biliary tract. Choledocholithiasis is the most common cause of biliary obstruction, with Escherichia coli, Klebsiella spp, and Enterococcus spp the most frequent biliary pathogens isolated in patients with cholangitis. Clinical presentation varies from mild illness to septic shock. The diagnosis of cholangitis is clinical and is supported by laboratory and radiographic findings. Initial treatment is supportive and includes antibiotics to cover the typical pathogens, but definitive treatment requires biliary drainage. Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred technique to achieve biliary decompression with placement of an internal or nasobiliary stent. In cases in which ERCP is unsuccessful or technically not feasible, percutaneous transhepatic biliary drainage (PTBD) is preferred over surgery, which carries significant morbidity and mortality. In order to prevent post-ERCP cholangitis, prophylactic antibiotics are recommended in patients undergoing ERCP for known or suspected biliary obstruction.     

十二指肠乳头插管困难时的操作策略

目的提高ERCP十二指肠乳头插管困难时的操作成功率。方法在常规插管方法失败时,采用超细导丝配合尖头导管插管技术、乳头预切开技术、导丝胰管占据技术、经皮经肝与ERCP对接技术等,来提高十二指肠乳头插管成功率。结果5年间内镜下行乳头插管5743例,插管成功5664例（98．6％）;其中发生乳头插管困难396例,分别采用以下技术：超细导管插管20例,胰管占据67例,预切开294例,对接法15例,共成功317例,成功率80．0％。结论根据乳头形态特点,合理运用各类特殊插管技术,注重操作配合技巧,可有效提高乳头插管困难者的操作成功率。     

EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases

BACKGROUND: Only a few cases have been reported of EUS-guided drainage of obstructed pancreatic or bile ducts. An initial experience with EUS-guided rendezvous drainage after unsuccessful ERCP is reported. METHODS: EUS-guided transgastric or transduodenal needle puncture and guidewire placement through obstructed pancreatic (n=4) or bile (n=2) ducts was attempted in 6 patients. Efforts were made to advance the guidewire antegrade across the papilla or surgical anastomosis. If guidewire passage was successful, rendezvous ERCP with stent placement was performed immediately afterward. RESULTS: EUS-guided duct access and intraductal guidewire placement was accomplished in 5 of 6 cases, with successful traversal of the obstruction, and rendezvous ERCP, with stent placement in 3 of 6 cases (two biliary, one pancreatic). The procedure was clinically effective in all successful cases (two patients with malignant obstructive jaundice, one with relapsing pancreatitis after pancreaticoduodenectomy). There was one minor complication (transient fever) but no pancreatitis or duct leak after successful or unsuccessful procedures. CONCLUSIONS: EUS is a feasible technique for allowing rendezvous drainage of obstructed biliary or pancreatic ducts through native papillae or anastomoses after initially unsuccessful ERCP.     

Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series

OBJECTIVES: Endoscopic retrograde cholangiography is an established method for treatment of common bile duct stones as well as for palliation of patients with malignant pancreaticobiliary strictures. It may be unsuccessful in the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic biliary drainage and surgery are alternative methods with a higher morbidity and mortality in these cases. Recently, endoscopic ultrasound (EUS) guided biliary stent placement has been described in patients with malignant biliary obstruction. We describe our experience with this method that was also used for the treatment of cholangiolithiasis for the first time. METHODS: The EUS guided transduodenal puncture of the common bile duct with stent placement was performed in 5 patients. In 2 of these patients, the stents were removed after several weeks and common bile duct stones were extracted. In another patient with gastrectomy, the left intrahepatic bile duct was punctured transjejunally and a metal stent was introduced transhepatically to bridge a distal common bile duct stenosis. RESULTS: Biliary decompression was successful in all 6 patients. No immediate complications occurred. One patient developed a subacute phlegmonous cholecystitis. CONCLUSIONS: Interventional EUS guided biliary drainage is a new technique that allows drainage of the biliary system in benign and malignant diseases when the bile duct is inaccessible by conventional ERCP.     

Magnetic resonance cholangiopancreatography for diagnosing hepatolithiasis

BACKGROUND/AIMS: Direct cholangiography with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography sometimes fails to adequately opacify the entire biliary tract, because of severe biliary obstruction caused by ductal stricture or lodged stones. We assessed the diagnostic accuracy of magnetic resonance cholangiopancreatography for hepatolithiasis. METHODOLOGY: Five patients with hepatolithiasis underwent ultrasonography, computed tomography, direct cholangiography, and magnetic resonance cholangiopancreatography, using a half-Fourier acquisition single-shot turbo spin-echo sequence. Surgical exploration or pathologic examination revealed stricture and dilatation of the intrahepatic ducts in all patients. Diagnostic accuracies for stones and ductal abnormalities were compared among the imaging studies. RESULTS: No complications occurred during magnetic resonance cholangiopancreatography studies. Magnetic resonance cholangiopancreatography fully depicted the biliary tract. Magnetic resonance cholangiopancreatography accurately detected and localized intrahepatic stones, as well as bile duct stricture and dilatation, in all patients. Intrahepatic stones were detected by endoscopic retrograde cholangiopancreatography in one of four patients and by percutaneous transhepatic cholangiography in all three who underwent this procedure. Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography demonstrated ductal stricture in all patients but failed to completely demonstrate the biliary tree in three of four patients, and one of three, respectively. On ultrasonography and computed tomography, precise localization of stones was difficult. Ultrasonography and computed tomography failed to demonstrate ductal stricture in one and two of the five patients, respectively. CONCLUSIONS: Magnetic resonance cholangiopancreatography diagnoses intrahepatic stones and bile duct abnormalities less invasively and more accurately than endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography.     

Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures(BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal(UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy.Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.CASE SUMMARY We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography(PTC) in both cases and after 6-weeks' maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy(PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically,and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.CONCLUSION PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

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.     

Percutaneous transhepatic sphincterotomy in the management of biliary tract disease

This report describes a novel modification of existing transhepatic techniques and illustrates successful relief of mechanical obstructive jaundice in 2 patients in whom surgical or endoscopic intervention was contraindicated or impossible. In each, percutaneous transhepatic cholangiogram (PTC) was performed in the usual manner. A standard endoscopic papillotome was then advanced across the stricture into the duodenum. Sphincterotomy was performed at the 11 to 1 o'clock position using blended current for 3-4 seconds. Repeat cholangiography showed successful decompression of the biliary tree in both patients. No morbidity or mortality was directly attributable to percutaneous transhepatic sphincterotomy in these patients. This technique offers a safe and therapeutic alternative to biliary tract obstruction, and should be considered in selected patients who are not candidates for surgery or endoscopy.     

Hepatobiliary complications in chronic pancreatitis.

Thirty nine patients undergoing surgery for chronic pancreatitis were investigated for evidence of hepatobiliary disease. In addition to pre-operative assessment by liver function tests, ultrasound, ERCP (in 33) and percutaneous transhepatic cholangiography (in five), all had peroperative liver biopsy. Common bile duct stenosis was diagnosed in 16 (62%) of the 26 patients with successful cholangiography. Features of extrahepatic biliary obstruction were found on biopsy in 11 patients, three of whom showed features of secondary sclerosing cholangitis. No patients had secondary biliary cirrhosis. Three had parenchymal liver disease (cirrhosis, resolving hepatitis and alcoholic hepatitis respectively) and two others had features suggestive of previous alcohol-induced injury. Five (83%) of the patients with clinical jaundice had biopsy features of extrahepatic biliary obstruction, as did eight (67%) with alkaline phosphatase above twice normal and seven (44%) with radiological common bile duct stenosis. Neither alkaline phosphatase rise, nor common bile duct stenosis alone or in combination, were a reliable indication of the need for biliary enteric bypass surgery. Pre-operative liver biopsy may be a valuable adjunct in the assessment of such patients.     

Magnetic compression anastomosis for the stricture of the choledochocholedochostomy after ABO-incompatible living donor liver transplantation

Biliary complications, such as stricture or obstruction after living donor liver transplantation (LDLT), are still major problems. Magnetic compression anastomosis (MCA) is a minimally invasive and nonsurgical procedure in patients with biliary structure or obstruction. A 49-year-old woman who had had ABO-incompatible LDLT 16 months previously presented with obstructive jaundice. After sufficient improvement of obstructive jaundice by percutaneous transhepatic cholangiodrainage (PTCD), the rendezvous technique between PTCD and endoscopic retrograde cholangiopancreatography was attempted in order to break through the stricture, but this was not successful. Therefore, MCA was performed. A parent magnet was endoscopically placed at the common bile duct side of the stricture, and the daughter magnet, attached to a guidewire, was also inserted to the intrahepatic bile duct. Both magnets were advanced to positions immediately prior to the biliary obstruction, and it was confirmed that the two magnets attracted each other magnetically, sandwiching the stricture. Twenty-four days after MCA, as recanalization could be achieved without any adverse events, the magnets were removed via the PTCD fistula. MCA enabled us to create a fistula without complications. In conclusion, when a conventional endoscopic or percutaneous approach, including the rendezvous technique, has failed, MCA is a novel method for patients with the stricture of the choledochocholedochostomy after LDLT.