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.     

Successful stent-in-stent dilatation of the common bile duct through a duodenal prosthesis,a novel technique for malignant obstruction:A case report and review of literature

For patients suffering from both biliary and duodenal obstruction,endoscopic retrograde cholangiopancreatography(ERCP) with stent placement is the treatment of choice.ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct(CBD).We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma.The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.     

Double balloon enteroscopy for endoscopic retrograde cholangiopancreaticography after Roux-en-Y reconstruction: case series and review of the literature

BACKGROUND: Endoscopic access to the biliary system can be difficult in patients with surgically altered anatomy, such as a Roux-en-Y reconstruction. Double balloon enteroscopy (DBE) is a relatively new procedure that enables access to the small bowel. DBE has recently been advocated as a method for endoscopic retrograde cholangiopancreaticography (ERCP) in patients with surgical reconstructions, with the potential to perform diagnostic and therapeutic interventions. METHODS: In three patients with a hepaticojejunostomy and Roux-en-Y reconstruction, the experiences using DBE to perform ERCP are described. The literature on DB-ERCP in patients with a Roux-en-Y reconstruction was reviewed. RESULTS: In all patients, the Roux limb was entered and a diagnostic cholangiography was carried out. In one patient, endoscopic therapy could be performed, consisting of balloon dilation of a stenotic biliodigestive anastomosis, repeated balloon dilation of biliary strictures and removal of bile casts. CONCLUSION: This series confirms recent data emerging from the literature that double balloon enteroscopy is a safe and feasible technique to obtain biliary access in patients with surgically altered anatomical configurations, such as those with a Roux-en-Y reconstruction. The diagnostic and therapeutic potential of DB-ERCP is great, and the utility of the procedure could be further improved if customised accessories become more widely available.     

Tips and tricks of double‐balloon endoscopic retrograde cholangiopancreatography (with video)

Although endoscopic retrograde cholangiopancreatography (ERCP) is technically difficult in patients with altered gastrointestinal tract, double‐balloon endoscopy (DBE) allows endoscopic access to pancreato‐biliary system in such patients. Balloon dilation of biliary stricture and extraction of bile duct stones, placement of biliary stent in patients with Roux‐en‐Y or Billroth‐II reconstruction, using DBE have been reported. However, two major technical parts are required for double‐balloon ERCP (DB‐ERCP). One is insertion of DBE and the other is an ERCP‐related procedure. The important point of DBE insertion is a sure approach to the afferent limb with Roux‐en‐Y reconstruction or Braun anastomosis. Short type DBE with working length 152 cm is beneficial for DB‐ERCP because it is short enough for most biliary accessory devices. In this paper, we introduce our tips and tricks for successful DB‐ERCP.     

Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred modality for drainage of the obstructed biliary tree. In patients with surgically altered anatomy, ERCP using standard techniques may not be feasible. Enteroscope assisted ERCP is usually employed with variable success rate. With advent of endoscopic ultrasound (EUS), biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective. In this narrative review, we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.     

Metal stents: a bridge to surgery in hilar cholangiocarcinoma

BackgroundObstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self‐expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma.MethodsA retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded.ResultsOf 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively.ConclusionsSelf‐expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re‐interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.     

Tips and troubleshooting for transpapillary metal stenting for distal malignant biliary obstruction

Endoscopic placement of a self‐expandable metal stent (SEMS) has become a mainstream treatment to relieve non‐resectable distal malignant biliary obstructions—its longer patency and cost‐effectiveness were demonstrated in comparison with plastic biliary stents in several randomized controlled trials. Despite advances in ERCP devices and SEMSs themselves to enable safe and effective biliary drainage via a SEMS, several significant aspects of the endoscopic placement of SEMS must be considered; otherwise, SEMS‐related complications and early SEMS dysfunction may occur. Also, SEMS dysfunction, including occlusion and migration, occurs at a certain frequency in the long term, and appropriate reintervention is necessary to preserve the quality of life of the patient. Here, we present tips for endoscopic transpapillary SEMS placement for distal malignant biliary obstruction and reintervention for SEMS dysfunction.     

Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device

Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.     

Metallic stent insertion with double-balloon endoscopy for malignant afferent loop obstruction

Progress in double-balloon endoscopy (DBE) has allowed for the diagnosis and treatment of disease in the postoperative bowel. For example, a short DBE, which has a 2.8 mm working channel and 152 cm working length, is useful for endoscopic retrograde cholangiopancreatography in bowel disease patients. However, afferent loop and Roux-limb obstruction, though rare, is caused by postoperative recurrence of biliary tract cancer with intractable complications. Most of the clinical findings involving these complications are relatively nonspecific and include abdominal pain, nausea, vomiting, fever, and obstructive jaundice. Treatments by surgery, percutaneous transhepatic biliary drainage, percutaneous enteral stent insertion, and endoscopic therapy have been reported. The general conditions of patients with these complications are poor due to cancer progression; therefore, a less invasive treatment is better. We report on the usefulness of metallic stent insertion using an overtube for afferent loop and Roux-limb obstruction caused by postoperative recurrence of biliary tract cancer under short DBE in two patients with complexly reconstructed intestines.     

消化道清洁对于预防内镜逆行胰胆管术后胆道感染的前瞻性随机对照研究

目的探讨口腔护理联合十二指肠冲洗对于预防ERCP术后胆道感染的作用。方法将573例梗阻性黄疸患者随机分为对照组190例（行常规ERCP诊疗）,盐水组（碘尔康漱口加生理盐水冲洗十二指肠乳头及内镜钳道,然后行ERCP诊疗）192例,抗生素组（碘尔康漱口加0．8％阿米卡星溶液冲洗后行ERCP诊疗）191例。术前收集患者临床资料,随访ERCP术后各组胆管炎发生率。结果3组在性别、年龄、梗阻部位、梗阻性质、术前总胆红素水平及白细胞计数的差异无统计学意义。对照组、盐水组及抗生素组ERCP术后胆管炎发生率分别为21．1％（40／190）、13．5％（26／192）和4．7％（9／191）,3组间差异有统计学意义（x2=22．409,P=0．000）。高、低位胆管梗阻胆管炎发生率分别为19．5％（65／333）和4．2％（10／240）,差异有统计学意义（x2=27．175,P=0．000）。而良、恶性梗阻胆管炎发生率差异无统计学意义（x2=0．449,P=0．503）。高位梗阻病例亚组分析结果示胆管炎发生率为：对照组29．7％（33／111例）、盐水组20．5％（24／117例）、抗生素组7．6％（8／105例）,3组间差异有统计学意义（x2=16．905,P=0．000）。结论高位胆管梗阻患者行ERCP诊疗更容易罹患胆管炎;在实施ERCP诊疗前,采用口腔护理联合肠道及内镜钳道冲洗能有效降低术后胆管炎的发生率,而采用抗生素溶液冲洗的效果更佳。     

ERCP在不明原因肝外阻塞性黄疸的临床应用

目的探讨内镜逆行胰胆管造影（ERCP）在经常规检查不明原因肝外阻塞性黄疸的临床应用价值。方法收集经B超、cT和,或MRCP检查诊断不明原因胆胰疾病或肝外胆管梗阻病人45例,男28例,女17例,年龄21—80岁,均行ERCP术。结果45例病人行ERCP术,其中42例诊断为胆道微结石（Biliary microlithiasis,BML）,42例均行乳头扩张术／EST4-胆道取石术;3例为胆总管下端炎性狭窄而行胆道内支架植入术;1例ERCP取石术后并发轻症胰腺炎,经内科保守治疗后痊愈,l例因腹痛再发行胆囊切除术,其余患者经ERCP治疗后腹痛、黄疸均缓解。结论BML是不明原因肝外阻塞性黄疸的主要原因,ERCP是不明原因肝外阻塞性黄疸安全、有效的诊断及治疗手段。     

内镜下金属支架引流术治疗肝门部胆管癌和肝外恶性胆道梗阻临床观察

临床上恶性胆道梗阻性疾病预后较差。对于不能手术切除者,通常选择内镜下置人胆道支架以解除梗阻,然而该技术对进展期肝门部肿瘤的疗效报道不一。目的：探讨内镜下金属支架引流术对肝门部胆管癌和肝外恶性胆道梗阻的疗效和并发症发生情况。方法：纳入上海交通大学附属第一人民医院2006年6月～2009年6月收治的82例接受ERCP下置入自膨式金属胆道支架引流治疗的恶性胆道狭窄患者,根据病变部位分为肝门部胆管癌组和肝外恶性胆道梗阻组,对其ERCP参数和术后6个月随访记录进行回顾性分析,并分析随访期间急性胆管炎发生的危险因素。结果：两组支架置入成功率均为100％。与肝外恶性胆道梗阻组相比,肝门部胆管癌组术后1周总胆红素降低显效率较低,术后6个月内急性胆管炎发生率增高,初次发生时间提前,支架再狭窄率增高（P=0．000）。ERCP术中括约肌切开为随访期间发生急性胆管炎的危险因素（P=0．004,OR：8．196）。结论：内镜下金属支架引流术对肝门部胆管癌的疗效不及肝外恶性胆道梗阻,且更易早期发生急性胆管炎和支架再狭窄,术中括约肌切开可增加术后急性胆管炎的发生风险。     

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.     

Contrast-free air cholangiography-assisted unilateral plastic stenting in malignant hilar biliary obstruction

BACKGROUND:Endoscopic palliation in malignant hilar biliary obstruction requires endoscopic retrograde cholangiopancreatography (ERCP),whereas contrast injection leads to cholangitis.Contrast-free metal stenting with or without magnetic resonance cholangiopancreatography (MRCP) has shown encouraging results,but MRCP and metal stents are costly.There have been no reports on the use of air cholangiography.METHODS:We prospectively evaluated the role of air cholangiography-assisted unilateral plastic stenting i...     

Simultaneous endoscopic ultrasound fine needle aspiration and endoscopic retrograde cholangio-pancreatography： Evaluation of safety

AIM： To investigate the rate of complications of endoscopic retrograde cholangio-pancreatography （ERCP） performed immediately after endoscopic ultrasound fine needle aspiration （EUS-FNA） in a large series of patients.
METHODS： Patients with the following conditions were considered candidates for EUS-FNA and ERCP： diagnosis of locally advanced or metastatic pancreatic lesion not eligible for surgery, and patients with pancreatic lesion of unknown nature causing jaundice. Data were prospectively collected on the following parameters： indication for FNA, EUS findings, pathological diagnosis, procedure duration of EUS-FNA and combined EUS-FNA and ERCP, and immediate and late complications.
RESULTS： From January 2004 to October 2006, 72 patients were deemed eligible for combined EUS and ERCP. In 25/72 EUS-FNA was performed to obtain a pathology diagnosis of lesions causing biliary obstruction, and ERCP sequentially performed to drain the biliary system. No immediate complications occurred except for two mild bleeding episodes post sphincterotomy. No late complications were recorded except for one patient who experienced fever, promptly recovered with antibiotic therapy.
CONCLUSION： Simultaneous approach appears to be feasible and safe. When possible, this can be considered the reference standard to avoid double sedation and reduce duration of the procedure and hospital stay.     

Endoscopic ultrasound-guided drainage of the biliary system:Techniques,indications and future perspectives

Over the last decade, endoscopic ultrasound-guided biliary drainage(EUS-BD)has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde cholangiopancreaticography(ERCP). The available evidence suggests that, in experienced hands, EUS-BD might even replace ERCP as the first-line procedure in specific situations such as malignant distal bile duct obstruction. The aim of this review is to summarize the available data on EUS-BD and propose an evidence-based algorithm clarifies the role of the different EUS-BD techniques in the management of benign and malignant biliary obstructive disease.     

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.     

Contrast-free unilateral endoscopic palliation in malignant hilar biliary obstruction: new method

BACKGROUND: Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast-free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast-free unilateral metal stenting in type II malignant hilar biliary obstruction. METHODS: We prospectively studied the results of unilateral metal stenting in type II malignant hilar biliary obstruction without contrast injection in 18 patients. RESULTS: A successful endoscopic drainage was achieved in 100% (18/18) of patients with hilar strictures. Cholangitis and 30-day mortality occurred in none. CONCLUSIONS: Unilateral endoscopic metal stenting without contrast in type II malignant hilar biliary obstruction is a safe and effective method of palliation.     

Removal of an embedded "covered" biliary stent by the "stent-in-stent" technique

A 46-year-old man was admitted with obstructive jaundice and cross-sectional imaging with computed tomography suggested distal biliary obstruction.A distal common bile duct stricture was found at endoscopic retrograde cholangiopancreatography(ERCP)and cytology was benign.A 6 cm fully covered self-expanding metal stent(SEMS)was inserted across the stricture to optimize biliary drainage.However,the SEMS could not be removed at repeat ERCP a few months later.A further fully covered SEMS was inserted within the existing stent to enable extraction and both stents were retrieved successfully a few weeks later.Fully covered biliary(SEMS)are used to treat benign biliary strictures.This is the first reported case of inability to remove a fully-covered biliary SEMS.Possible reasons for this include tissue hyperplasia and consequent overgrowth into the stent proximally,or chemical or mechanical damage to the polymer covering of the stent.Application of the stent-in-stent technique allowed successful retrieval of the initial stent.