Treatment of biliary obstruction by (EUS)-guided transluminal biliary drainage

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Treatment of biliary

obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal

biliary drainage

U. Will, A. Thieme, F. Fueldner, R.

Gerlach, I. Wanzar,

F. Meyer

Department of Internal Medicine & Surgery University Hospital, Magdeburg, Germany

Background

and study aims: Endoscopic retrograde cholangiopancreatography (ERCP)-guided implantation of a

biliary endoprosthesis or stent is the gold

standard treatment for biliary obstructions. When

the papilla cannot be traversed because there is pyloric or duodenal

stenosis, or the catheter cannot be introduced, or because of previous

gastrointestinal surgery (Billroth II gastric

resection, Whipple procedure, gastrectomy with

Roux-en-Y reconstruction), the alternative treatment is considered to be percutaneous transhepatic cholangiography and drainage (PTCD). The

aim of the study was to investigate the further alternative of endoscopic ultrasound (EUS)-guided transgastric

or transjejunal biliary drainage where PTCD failed

or was declined, and particularly, the feasibility and outcome of this

option.

Patients

and methods: Over 3 years all appropriate consecutive

patients (as defined above) were enrolled in this prospective, observational,

single-center, case series study, and patient and intervention data were

recorded. Feasibility was characterized by success

rate (regression of cholestasis), and outcomes by

complication rate, mortality, and follow-up findings.

Results:

Between November 2002 and December 2005, eight patients (in 10 interventions)

underwent this new biliary drainage procedure. The

routes were transesophageal (n = 1), transgastric (n = 4), and transjejunal

(n = 3, including a rendezvous technique with ERCP [n = 1]).

The indications were cholestasis, arising

from recurrent tumor growth (n = 5, 62.5 %), that included gastric carcinoma

after previous gastrectomy (n = 4) and a periampullary carcinoma after previous Whipple procedure

(n = 1); arising from Klatskin tumor (n = 2, 25 %);

and from benign stenosis of a hepaticojejunostomy

(n = 1, 12.5 %). Five patients (62.5 %) received a

metal stent, and three (37.5 %) had a plastic prosthesis (8.5-Fr

double-pigtail). The technical success rate was 90 %

(9/10) and the clinical success rate was 88.9 % (8/9). There

was only one case of cholangitis (12.5 %) and

slight postinterventional pain, but no severe

complications such as bleeding or perforation, and no mortality. During follow-up (range 4 weeks to 3 years)

re-interventions were needed in two patients (20 %) because of increasing cholestasis; these resulted in technical success and

clinical improvement.

Conclusion:

EUS-guided transgastric or transjejunal

biliary drainage is a reasonable, feasible and encouraging treatment option

in selected patients as indicated, with a low peri-interventional

risk. It broadens the therapeutic spectrum but still

needs further evaluation and follow-up investigation.

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