Comparison of endosonography-guided vs. percutaneous biliary stenting when papilla is inaccessible for ERCP

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting fails in 5-10% patients of malignant biliary obstruction because papilla is inaccessible. Percutaneous transhepatic biliary drainage (PTBD) is an accepted alternative. Endosonography-guided biliary drainage (EUS-BD) has been described recently.

Aim: To compare success rates and complications of EUS-BD and PTBD internal stenting.

Methods: This retrospective study included failed ERCP in inoperable malignant biliary obstruction due to inaccessible papilla undergoing PTBD or EUS-BD. Percutaneous transhepatic cholangiography guided/EUS-guided rendezvous procedures were excluded. When PTBD internal stenting failed, external drainage was performed. EUS-BD was performed using either intra- or extrahepatic approach, and stents were placed by transmural (choledocho-duodenostomy or hepatico-gastrostomy) or antegrade approach. Self-expandable metallic stents or plastic stents were placed in both groups. Success of internal stenting and complications were compared using t-test and chi-squared test.

Results: Retrospective review of 6 years of records (2005-2011) revealed 50 patients meeting the required criteria. EUS-BD was attempted in 25 and PTBD in 26 patients (one crossover from EUS-BD to PTBD). Internal stenting was technically and clinically successful in 23/25 (92%) EUS-BD vs. 12/26 (46%) PTBD (p < 0.05). External catheter drainage was performed in remaining 14 PTBD patients. Complications occurred in 5/25 (20%) EUS-BD (one major, four minor) and in 12/26 (46%) PTBD (four major, eight minor; p < 0.05). Late stent occlusion occurred in one EUS-BD and three PTBD.

Conclusions: In this retrospective study comparing success and complications of EUS-BD and PTBD in patients with inoperable malignant biliary obstruction and inaccessible papilla, EUS-BD was found superior to PTBD for both comparators.

Keywords: EUS; PTBD; biliary drainage; biliary stenting; choledocho-duodenostomy; hepatico-gastrostomy; interventional EUS; therapeutic endosonography.

Figures

Figure 1.

EUS choledocho-duodenostomy. (a) EUS-guided puncture of the dilated common bile duct from the duodenal bulb. (b) cholangiogram showing dilated biliary tree and duodenal stent in situ, (c, d) Fluoroscopy, showing EUS-CD with deployed self-expandable metallic stents (c) and endoscopic view (d).

Figure 2.

EUS hepatico-gastrostomy. (a) EUS-guided puncture of dilated intrahepatic biliary radicle. (b) Cholangiogram showing dilated common bile duct and intrahepatic biliary radicle. (c, d) Fluoroscopy, showing EUS-HG with deployed self-expandable metallic stents (c) and endoscopic view (d).

Figure 3.

EUS antegrade transpapillary approach. (a) EUS-guided cholangiogram with guide-wire crossing the ampulla. (b) Antegrade biliary self-expandable metallic stents across the papilla. Duodenal stent seen in situ.