Endoscopic Ultrasound-Guided Antegrade Radiofrequency Ablation and Metal Stenting With Hepaticoenterostomy for Malignant Biliary Obstruction: A Prospective Preliminary Study

Abstract

OBJECTIVES: Endobiliary radiofrequency ablation (RFA) for malignant biliary obstruction is a promising option for improving biliary stent patency, but its efficacy and safety with endoscopic ultrasound (EUS)-guided biliary drainage are uncertain. We examined the feasibility of EUS-guided hepaticoenterostomy with antegrade stenting (EUS-HEAS) and RFA in patients with unresectable malignant biliary obstruction. METHODS: This was a prospective, single-center, single-arm, preliminary study. Twenty patients who met the eligibility criteria for inclusion between August 2018 and January 2020 were enrolled. We evaluated the technical success, functional success, recurrent biliary obstruction (RBO), and adverse events other than RBO associated with EUS-HEAS with RFA. RESULTS: The technical and functional success rates were both 80% (16/20). The procedure was unsuccessful in a total of 4 patients due to failure to insert the RFA catheter through the fistula (2 patients) or failure to pass the RFA catheter through the stricture (2 patients). Early and late adverse events other than RBO occurred in 10% (2/20) and 13% (2/16) of subjects, respectively. The RBO rate was 25% (4/16), and the median time to RBO was 276 days. The success rate of endoscopic reintervention using hepaticoenterostomy was 100% (4/4). DISCUSSION: This preliminary study showed that EUS-HEAS with RFA achieves good results but RFA catheter insertion can be difficult. Further evaluation and device improvements are warranted.

Updated evidence on the clinical impact of endoscopic radiofrequency ablation in the treatment of malignant biliary obstruction

“…12 The ELRA catheter is a 7-Fr bipolar catheter with a 1750mm length and has two to four ring electrodes in its terminal segment. There are four types with different exposure lengths (11,18,22, and 33 mm) for this device (Fig. 2B); therefore, it may be applicable to strictures of various lengths.…”

Hyperkalemia after endobiliary radiofrequency ablation for malignant biliary obstruction

“…The fistula was dilated using a 4-mm dilatation balloon catheter, and a Habib EndoHPB Catheter (Boston Scientific, Marlborough, MA, USA) was inserted. Subsequently, the stricture was ablated at a power of 7W for 90 s. 1 A metallic stent was deployed antegrade across the stricture, and a single-pigtail plastic stent was deployed across the fistula (Fig. 1).…”

“…Digital single-operator cholangioscopy (DSOC) has revolutionized the endoscopic diagnosis and treatment of various hepato-pancreaticobiliary diseases, such as indeterminate biliary strictures and large balloon dilation-refractory common bile duct (CBD) stones, using either a retrograde or antegrade approach. 1,2 Direct visualization provided by DSOC has furthermore paved the road towards minimally invasive treatment of intraductal neoplasms, although little evidence is available in this specific context.…”

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possess some degree of inherent limitations. [1][2][3] However, the development of the second-generation single-operator cholangioscopy system (SpyGlassDS; Boston Scientific, Watertown, MA, USA) has resulted in a significant improvement in the diagnostic sensitivity to 75-85%, and we have recently shown in a randomized trial that an accurate diagnosis can be established in 90% of patients with indeterminate biliary strictures. 4,5 Recently, new cholangioscopy biopsy forceps have been developed (SpyBite Max Biopsy Forceps; Boston Scientific) with a larger jaw outer diameter of 1.0 mm, with the aim of procuring a greater quantity of tissue.

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Endobiliary radiofrequency ablation through an EUS-guided hepaticogastrostomy fistula for hilar malignant biliary stenosis

“…Endobiliary radiofrequency ablation (RFA) for malignant biliary strictures due to unresectable cholangiocarcinoma is reportedly expected to prolong the patency of self-expandable metallic stents (SEMS) [1][2][3]. Transpapillary endoscopic retrograde cholangiopancreatography (ERCP) has been reported for endobiliary RFA; however, a few reports discuss the approach from the fistula made during endoscopic ultrasound biliary drainage (EUS-BD) [4][5]. In a 75-year-old man with hilar cholangiocarcinoma ( ▶ Fig.…”