Endoscopic ultrasound-guided hepaticogastrostomy and antegrade clearance of biliary lithiasis in patients with surgically-altered anatomy

Abstract

Background and study aims Endoscopic retrograde cholangiography (ERC) in patients with complex surgically-altered anatomy (SAA) is technically demanding and has limitations. Developments in EUS-guided procedures allow alternative approaches for patients with altered gastrointestinal anatomy and biliary lithiasis. Patients and methods Single-center, retrospective review of prospectively entered patients with SAA who underwent EUS-guided hepaticogastrostomy (HGS) followed by an interval antegrade endoscopic clearance of biliary lithiasis. Results 9 patients with Roux-en-Y anatomy underwent HGS to allow clearance of biliary lithiasis after a mean of 2.5 procedures. Technical success was achieved in 100 % of patients utilizing subsequent antegrade endoscopic techniques after HGS including: balloon sweep (9), transpapillary balloon dilation (8), cholangioscopy with electrohydraulic lithotripsy (4), and mechanical lithotripsy (1). HGS stents were removed in all patients. 1 adverse event (cholangitis) occurred after cholangioscopy and prolonged intraductal electrohydraulic lithotripsy. Conclusion EUS-guided antegrade therapy for the management of biliary lithiasis in patients with altered gastrointestinal anatomy appears efficacious with a low risk of adverse events. These preliminary results suggest this approach should be considered at centers with available expertise.

Relief of biliary obstruction: choosing between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography

“…Another group applied this technique in nine patients with Roux-en-Y anatomy and achieved technical success in all subjects, with only one reported AE of cholangitis following prolonged lithotripsy. 92 In the absence of an acute infection or pancreatitis, we recommend that EUS-guided gastrogastrostomy be considered in patients with RYGB anatomy. Initially described in 2014, this novel technique enables an endoscopist to exclude the stomach by creating a fistulous tract via LAMS in order for the duodenoscope to pass through so conventional ERCP can be utilised.…”

Management of Difficult Bile Duct Stones by Large Balloon, Cholangioscopy, Enteroscopy and Endosonography

“…Intraductal lithotripsy can be performed using ML or POCS-guided lithotripsy, which was increasingly reported in recent papers. [48][49][50] The mature fistula can be readily dilated using a bougie dilator or a balloon dilator before device insertion, depending on the size of devices used for lithotripsy. While ML can be introduced into the bile duct through the fistula over the guidewire easily, dilation up to 10-F is necessary if digital cholangioscopy-assisted lithotripsy is necessary after EUS-HGS or EUS-HJS using a plastic stent.…”

“…51 While most EUS-BD procedures were initially performed for unresectable malignant biliary obstruction, advanced EUS-guided management of benign biliary diseases including complex BDS has been increasingly reported (Table 4). Hosmer et al 48 reported a single center experience of nine cases with Roux-en-Y anatomy with the technical success rate of stone extraction was 100%. Balloon dilation of the ampulla ≥10 mm was performed in 89% and cholangioscopy-assisted EHL was performed in 44%.…”

Interventional endoscopic ultrasonography in patients with surgically altered anatomy: Techniques and literature review

“…24 Table 3 summarizes the main reports of EUS-AI. Based on these reports, 19,21,22,[25][26][27][28][29][30][31] the procedure success rate ranges from 57.1% to 100%, and the incidence of adverse events ranges from 0% to 33%.…”