Endoscopic Ultrasound Guided Biliary Drainage in Patients with Unapproachable Ampullae Due to Malignant Duodenal Obstruction |
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Authors: | Paul J Belletrutti Christopher J DiMaio Hans Gerdes Mark A Schattner |
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Institution: | 1. Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, P.O. Box?273, New York, NY, 10065, USA
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Abstract: | Purpose When endoscopic retrograde cholangiopancreatography (ERCP) is not possible due to duodenal obstruction, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternate mode of biliary decompression. This study aims to determine the safety and outcomes of performing EUS-BD in such patients. Methods A retrospective review of our endoscopy procedure database was carried out to identify patients with malignant biliary obstruction and failed ERCP in whom EUS-BD was attempted. Results Seven patients were identified. The technical success rate was 6/7 (86%). Four patients were treated with a choledochoduodenostomy; two had hepaticogastrostomies; drainage was not attempted in one due to unfavorable anatomy on EUS. In three patients, EUS-BD was performed immediately after unsuccessful ERCP as a single procedure. The initial choice of stent was plastic in two, self-expanding uncovered metal in two, and fully covered metal in two. The median follow-up was 15.5?weeks. There were no immediate complications. Bilirubin decreased in 5/6 (83%) and jaundice resolved in 4/6 (67%). Pruritus resolved in 4/4 (100%). Chemotherapy was restarted in 4/6 (67%). Reintervention due to stent blockage occurred twice. Both were converted to fully covered metal stents. No instances of stent migration were observed. Conclusions In our series, EUS-BD is a feasible, safe, and effective method of internal drainage in appropriately selected patients with biliary obstruction and unapproachable ampullae due to malignant duodenal obstruction. EUS-BD can be performed immediately after a failed ERCP under the same anesthesia. Covered metal stents may be preferred, but further study is required. |
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