Background A single session of EUS-guided biliary drainage (EUS-BD) may be a viable alternative to ERCP in patients with malignant distal common bile duct (CBD) obstruction. There is no study ...comparing EUS-BD and ERCP for the relief of distal malignant biliary obstruction. Objective To compare the outcomes of self-expandable metal stent (SEMS) placement for malignant distal biliary obstruction by using ERCP and EUS-BD. Study Design Multicenter, retrospective analysis. Setting Tertiary referral centers. Patients Patients with malignant distal CBD obstruction requiring SEMS placement. Interventions Patients in the EUS-BD group underwent EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade (EUS-AG) procedures after 1 or more failed ERCP attempts. Patients in the ERCP group underwent retrograde SEMS placement. Main Outcome Measurements Composite success (the ability to complete the intended therapeutic procedure in a single session and resulting in a greater than 50% decrease in bilirubin over 2 weeks). Results The study included 208 patients, 104 treated with ERCP and 104 treated with EUS-BD (68 EUS-CDS, 36 EUS-AG). SEMS placement was successful in 98 patients in the ERCP group and 97 in the EUS-BD group (94.23% vs 93.26%, P = 1.00). The frequency of adverse events in the ERCP and EUS-BD groups was 8.65% and 8.65%, respectively. Postprocedure pancreatitis rates were higher in the ERCP group (4.8% vs 0, P = .059). The mean procedure times in the ERCP and EUS-BD groups were similar (30.10 and 35.95 minutes, P = .05). Limitations Retrospective analysis. Conclusions In patients with malignant distal CBD obstruction requiring SEMS placement, the short-term outcome of EUS-BD is comparable to that of ERCP.
Background EUS-guided biliary drainage (EUS-BD) has emerged as an alternative rescue method in patients with failed ERCP. Opportunities for teaching and training are limited because of a low case ...volume at most centers. Objective To evaluate a stereolithography/3-dimensional (3D) printing bile duct prototype for teaching and training in EUS-BD. Design Prospective observational feasibility study. Setting Tertiary referral center. Subjects Twenty endosonographers attending an interventional EUS workshop. Intervention A prototype of a dilated biliary system was prepared by computer-aided design and 3D printing. The study participants performed guidewire manipulation and EUS-BD procedures (antegrade procedure and/or choledochoduodenostomy) on the prototype. Participants were scored with the device on a scale of 1 to 5 via a questionnaire. Participants’ success rate for various steps of the EUS-BD procedure was noted. Main Outcome Measurements Subjective and objective evaluation of the prototype regarding its overall applicability, quality of radiographic and EUS images, and 4 steps of EUS-BD procedure (needle puncture, guidewire manipulation, tract dilation, stent placement). Results Fifteen participants returned the questionnaire, and 10 completed all 4 steps of EUS-BD. The median score for overall utility was 4, whereas that for EUS and US views was 5. Participants with experience in performing more than 20 EUS-BD procedures scored the prototype significantly lower for stent placement ( P = .013) and equivalent for needle puncture, tract dilation, and wire manipulation. The success rate of various steps was 100% for needle puncture and tract dilation, 82.35% for wire manipulation, and 80% for stent placement. The mean overall procedure time was 18 minutes. Limitations Small number of participants. Conclusion The 3D printing bile duct prototype appears suitable for teaching of and training in the various steps of EUS-BD. Further studies are required to elucidate its role.
Background Precut papillotomy after failed bile duct cannulation is associated with an increased risk of pancreatitis. EUS-guided rendezvous drainage is a novel alternative technique, but there are ...no data comparing this approach with precut papillotomy. Objective To evaluate the safety and efficacy of EUS-guided rendezvous drainage of the bile duct and compare its outcome with that of precut papillotomy. Design Retrospective study. Setting Tertiary care referral center. Patients Consecutive patients with distal bile duct obstruction, in whom selective cannulation of the bile duct at ERCP failed after 5 attempts with a guidewire and sphincterotome, underwent an EUS-guided rendezvous procedure. The outcomes were compared with those in a historical cohort of patients who underwent precut papillotomy. Interventions Patients in whom selective cannulation failed underwent EUS-guided rendezvous drainage by use of the short wire technique or precut papillotomy by use of the Erlangen papillotome. At EUS, after the extrahepatic bile duct was punctured with a 19-gauge needle, a hydrophilic angled-tip guidewire 260 cm long was passed in an antegrade manner across the papilla into the duodenum. The echoendoscope was then exchanged for a duodenoscope, which was introduced alongside the EUS-placed guidewire. The transpapillary guidewire was retrieved through its biopsy channel, and accessories were passed over the wire to perform the requisite endotherapy. Main Outcome Measures Comparison of the rates of technical success and complications between patients treated by the EUS-guided rendezvous and those treated by precut papillotomy techniques. Treatment success was defined as completion of the requisite endotherapy in one treatment session. Results Treatment success was significantly higher for the EUS-guided rendezvous (57/58 patients) than for those undergoing precut papillotomy technique (130/144 patients) (98.3% vs 90.3%; P = .03). There was no significant difference in the rate of procedural complications between the EUS and precut papillotomy techniques (3.4% vs 6.9%, P = .27). Limitations Retrospective nonrandomized study design; highly selective patient cohort. Conclusions In this study, the EUS-guided rendezvous technique was found to be superior to precut papillotomy for single-session biliary access. Prospective randomized trials are needed to confirm these preliminary but promising findings.
Background Scant data exist on the utility of the holmium:yttrium-aluminum-garnet laser for the treatment of biliary or pancreatic duct stones. Objective To evaluate the efficacy and safety of ...fiberoptic probe and catheter system-guided holmium laser lithotripsy of difficult biliary and pancreatic duct stones. Design Prospective study. Setting Tertiary-care referral center. Patients This study involved 64 patients who underwent holmium laser stone fragmentation. Intervention A total of 64 patients (60 bile duct stones, 4 pancreatic duct stones) underwent endoscopic retrograde stone fragmentation with a holmium laser and a fiberoptic probe and catheter system. The inclusion criterion for bile duct stones was stones not amenable to retrieval by mechanical lithotripsy and/or balloon sphincteroplasty or standard techniques. Pancreatic duct stones included in this study were not amenable to removal by stone retrieval basket or balloon. Main Outcome Measurements Rates of ductal clearance and procedural complications. Results All 64 patients had successful fragmentation of biliary and pancreatic duct stones with the holmium laser. Fifty of 60 patients (83.3%) had complete biliary duct clearance after a single session; 10 patients required an additional session. All pancreatic duct stones were fragmented in a single session. Mean duration of ERCP sessions was 45.9 minutes (range 30-90 minutes). Complications were mild and were encountered in 13.5% of patients; fever (n = 3), transient abdominal pain (n = 4), and biliary stricture (n = 1). Limitations No comparative treatment group. Conclusion The fiberoptic probe and catheter system facilitates transpapillary access for holmium laser fragmentation of difficult biliary and pancreatic duct stones. The technique is safe and highly effective for single-setting duct clearance. Complications are minimal and transient.
Background EUS-guided pseudocyst drainage with fully covered self-expandable metal stents (FCSEMSs) was recently described. The appropriate period for stent removal is not known. Objective To assess ...the safety and efficacy of EUS-guided FCSEMS placement for 3 weeks, along with pancreatic ductal stenting in selected patients. Study Design Prospective, single-center evaluation. Setting Tertiary referral center. Patients Symptomatic pseudocysts in the body and tail region of the pancreas. Interventions EUS-guided transgastric placement of FCSEMS. MRCP was performed after 3 weeks. Patients with a suspected pancreatic duct leak underwent ERCP and plastic stent placement. The FCSEMSs were removed at 3 weeks. Main Outcome Measurements Success of FCSEMS placement, adverse events, and recurrence rate. Results Forty-seven patients met the eligibility criteria. Technical and functional success was achieved in 43 patients (intention to treat, 91.48% and 95.34% patients per protocol, 41/43, respectively). Adverse events occurred in 2 patients (cyst infections, 4.6%). Follow-up of 42 patients at 3 weeks was performed. MRCP detected a ductal leak in 3 patients (7.1%) and a disconnected duct in 2 patients (4.7%). ERCP and stenting were successful in all 3 patients with a ductal leak. During a median follow-up of 306 days in 42 patients, 2 recurrences (4.7%) were detected, both in patients with disconnected duct. Multivariate analysis showed that pancreatic ductal leak or disconnection was an independent factor affecting pseudocyst resolution at 3 weeks ( P = .0001). Limitations Single-center study. Conclusion Short-term placement of FCSEMSs with pancreatic ductal stenting in selected patients appears safe and effective for the treatment of pseudocysts.
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