International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs. choledochoduodenostomy approaches

Mouen A Khashab, Ahmed A Messallam, Irene Penas, Yousuke Nakai, Rani J Modayil, Carlos De la Serna, Kazuo Hara, Mohamad El Zein, Stavros N Stavropoulos, Manuel Perez-Miranda, Vivek Kumbhari, Saowanee Ngamruengphong, Vinay K Dhir, Do Hyun Park, Mouen A Khashab, Ahmed A Messallam, Irene Penas, Yousuke Nakai, Rani J Modayil, Carlos De la Serna, Kazuo Hara, Mohamad El Zein, Stavros N Stavropoulos, Manuel Perez-Miranda, Vivek Kumbhari, Saowanee Ngamruengphong, Vinay K Dhir, Do Hyun Park

Abstract

Background and study aims: Endoscopic ultrasound-guided biliary drainage (EUS-BD) can be performed entirely transgastrically (hepatogastrostomy/EUS-HG) or transduodenally (choledochoduodenostomy/EUS-CDS). It is unknown how both techniques compare. The aims of this study were to compare efficacy and safety of both techniques and identify predictors of adverse events.

Patients and methods: Consecutive jaundiced patients with distal malignant biliary obstruction who underwent EUS-BD at multiple international centers were included. Technical/clinical success, adverse events, stent complications, and survival were assessed.

Results: A total of 121 patients underwent EUS-BD (CDS 60, HG 61). Technical success was achieved in 112 (92.56 %) patients (EUS-CDS 93.3 %, EUS-HG 91.8 %, P = 0.75). Clinical success was attained in 85.5 % of patients who underwent EUS-CDS group as compared to 82.1 % of patients who underwent EUS-HG (P = 0.64). Adverse events occurred more commonly in the EUS-HG group (19.67 % vs. 13.3 %, P = 0.37). Both plastic stenting (OR 4.95, 95 %CI 1.41 - 17.38, P = 0.01) and use of non-coaxial electrocautery (OR 3.95, 95 %CI 1.16 - 13.40, P = 0.03) were independently associated with adverse events. Length of hospital stay was significantly shorter in the CDS group (5.6 days vs. 12.7 days, P < 0.001). Mean follow-up duration was 151 ± 159 days. The 1-year stent patency probability was greater in the EUS-CDS group [0.98 (95 %CI 0.76 - 0.96) vs 0.60 (95 %CI 0.35 - 0.78)] but overall patency was not significantly different. There was no difference in median survival times between the groups (P = 0.36) CONCLUSIONS: Both EUS-CDS and EUS-HG are effective and safe techniques for the treatment of distal biliary obstruction after failed ERCP. However, CDS is associated with shorter hospital stay, improved stent patency, and fewer procedure- and stent-related complications. Metallic stents should be placed whenever feasible and non-coaxial electrocautery should be avoided when possible as plastic stenting and non-coaxial electrocautery were independently associated with occurrence of adverse events.

Conflict of interest statement

Competing interests: Dr. Khashab is a consultant for Boston Scientific, Xlumena and Olympus America and has received research support from Cook Medical.

Figures

Fig. 1
Fig. 1
Fluoroscopic images demonstrating metallic stents across created choledochoduodenostomy (a) and hepatogastrostomy (b).
Fig. 2
Fig. 2
Kaplan-Meier plot estimates of the stent patency duration after EUS-CDS and EUS-HG. Dashed line represents probability of stent patency at 1 year: EUS-CDS 0.98 (96 %CI: 0.76 – 0.96) vs EUS-HG 0.60 (95 %CI: 0.35 – 0.78). Stent patency duration was not significantly different via log-rank test (P = 0.228).
Fig. 3
Fig. 3
Kaplan-Meier plot estimates of the overall survival after EUS-CDS and EUS-HG. Median survival times (95 % CI) were 252 days (131 – 369) for EUS-CDS and 142 days (82 – 256) for EUS-HG. There was no significant difference in survival times between the two groups (P = 0.357 via log rank test). Survival probabilities (95 % CI) at 6 months were EUS-CDS 0.57 (0.41 – 0.71) vs EUS-HG 0.44 (0.30 – 0.57); and at 1 year, EUS-CDS 0.39 (0.22 – 0.55) vs EUS-HG 0.20 (0.09 – 0.35), as indicated by the dashed line.

References

    1. Khashab M A, Varadarajulu S. Endoscopic ultrasonography as a therapeutic modality. Curr Opin Gastroenterol. 2012;28:467–476.
    1. Kahaleh M, Hernandez A J, Tokar J. et al.Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc. 2006;64:52–59.
    1. Maranki J, Hernandez A J, Arslan B. et al.Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography. Endoscopy. 2009;41:532–538.
    1. Kim Y S, Gupta K, Mallery S. et al.Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series. Endoscopy. 2010;42:496–502.
    1. Fabbri C, Luigiano C, Fuccio L. et al.EUS-guided biliary drainage with placement of a new partially covered biliary stent for palliation of malignant biliary obstruction: a case series. Endoscopy. 2011;43:438–441.
    1. Komaki T, Kitano M, Sakamoto H. et al.Endoscopic ultrasonography-guided biliary drainage: evaluation of a choledochoduodenostomy technique. Pancreatology. 2011;11:47–51.
    1. Park D H, Jang J W, Lee S S. et al.EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc. 2011;74:1276–1284.
    1. Hara K, Yamao K, Niwa Y. et al.Prospective clinical study of EUS-guided choledochoduodenostomy for malignant lower biliary tract obstruction. Am J Gastroenterol. 2011;106:1239–1245.
    1. Iwashita T, Lee J G, Shinoura S. et al.Endoscopic ultrasound-guided rendezvous for biliary access after failed cannulation. Endoscopy. 2012;44:60–65.
    1. Khashab M, Fujii L L, Baron T H. et al.EUS-guided biliary drainage for patients with malignant biliary obstruction with an indwelling duodenal stent (with video) Gastrointest Endosc. 2012;76:209–213.
    1. Henry W A, Singh V K, Kalloo A N. et al.Simultaneous EUS-guided transbulbar pancreaticobiliary drainage (with video) Gastrointest Endosc. 2012;76:1065–1067.
    1. Dhir V, Bhandari S, Bapat M. et al.Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos) Gastrointest Endosc. 2012;75:354–359.
    1. Shah J N, Marson F, Weilert F. et al.Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla. Gastrointest endosc. 2012;75:56–64.
    1. Khashab M A, Valeshabad A K, Modayil R. et al.EUS-guided biliary drainage by using a standardized approach for malignant biliary obstruction: rendezvous versus direct transluminal techniques (with videos) Gastrointest Endosc. 2013;78:734–741.
    1. Khashab M A, Valeshabad A K, Afghani E. et al.A comparative evaluation of EUS-guided biliary drainage and percutaneous drainage in patients with distal malignant biliary obstruction and failed ERCP. Dig Dis Sci. 2015;60:557–565.
    1. Itoi T, Yamao K. EUS 2008 Working Group document: evaluation of EUS-guided choledochoduodenostomy (with video) Gastrointest Endosc. 2009;69:8–S12.
    1. Savides T J, Varadarajulu S, Palazzo L. EUS 2008 Working Group document: evaluation of EUS-guided hepaticogastrostomy. Gastrointest Endosc. 2009;69:S3–S7.
    1. Artifon E L, Safatle-Ribeiro A V, Ferreira F C. et al.EUS-guided antegrade transhepatic placement of a self-expandable metal stent in hepatico-jejunal anastomosis. J Oncol Pract. 2011;12:610–613.
    1. Nguyen-Tang T, Binmoeller K F, Sanchez-Yague A. et al.Endoscopic ultrasound (EUS)-guided transhepatic anterograde self-expandable metal stent (SEMS) placement across malignant biliary obstruction. Endoscopy. 2010;42:232–236.
    1. Cotton P B, Eisen G M, Aabakken L. et al.A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71:446–454.
    1. Khashab M A, Kumbhari V, Kalloo A N. et al.EUS-guided biliary drainage by using a hepatogastrostomy approach. Gastrointest Endosc. 2014;78:675.
    1. Dhir V, Bhandari S, Bapat M. et al.Comparison of transhepatic and extrahepatic routes for EUS-guided rendezvous procedure for distal CBD obstruction. United European Gastroenterol J. 2013;1:103–108.
    1. Park do H, Jeong S U, Lee B U. 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.
    1. Dhir V, Artifon E L, Gupta K. et al.Multicenter study on endoscopic ultrasound-guided expandable biliary metal stent placement: Choice of access route, direction of stent insertion, and drainage route. Dig Endosc. 2014;26:430–435.
    1. Artifon E L, Marson F P, Gaidhane M. et al.Hepaticogastrostomy or choledochoduodenostomy for distal malignant biliary obstruction after failed ERCP: is there any difference? Gastrointest Endosc. 2015;81:950–959.
    1. Gupta K, Perez-Miranda M, Kahaleh M. et al.Endoscopic ultrasound-assisted bile duct access and drainage: multicenter, long-term analysis of approach, outcomes, and complications of a technique in evolution. J Clin Gastroenterol. 2014;48:80–87.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe