Outcomes and limitations of endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction

Abstract

Background Transpapillary biliary drainage in ERCP is an established method for symptomatic treatment of patients with unresectable malignant biliary obstruction. Percutaneous transhepatic biliary drainage frequently remains the treatment of choice when the transpapillary approach proves ineffective. Recently, EUS-guided extra-anatomical anastomoses of bile ducts to the gastrointestinal tract have been reported as an alternative to percutaneous biliary drainage. To assess the usefulness of extra-anatomical intrahepatic biliary duct anastomoses to the gastrointestinal tract as endotherapy for unresectable malignant biliary obstruction and to determine factors affecting the efficacy of treatment. Methods A prospective analysis of the treatment results of all patients with unresectable biliary obstruction treated with EUS-guided hepaticogastrostomy at our institution in the years 2016–2019. Results Transmural intrahepatic biliary drainage (EUS-guided hepaticogastrostomy) was performed due to the ineffectiveness of ERCP in 53 patients (38 males, 15 females; mean age 74.66 [56–89] years) with unresectable biliary obstruction. Technical success of EUS-guided hepaticogastrostomy was achieved in 52/53 (98.11%) patients. Complications of endoscopic treatment were observed in 10/53 (18.87%) patients. Clinical success of EUS-guided hepaticogastrostomy was achieved in 46/53 (86.79%) patients. Bismuth type II–IV cholangiocarcinoma, hepatic metastases, ascites, suppurative cholangitis, and high blood bilirubin levels exceeding 30 mg/dL were independent factors for increased complications and inefficacy of EUS-guided hepaticogastrostomy. Conclusions In the event of transpapillary biliary drainage proving ineffective, extra-anatomical anastomoses of intrahepatic bile ducts to the gastrointestinal tract provide an effective method for the treatment of patients with malignant biliary obstruction.

Preoperative Endoscopic Ultrasound-Guided Hepaticogastrostomy for Definite Biliary Drainage in Hilar Cholangiocarcinoma Laparoscopic Resection: A Hybrid Minimal-Invasive Technique

“…16,17 EHG has recently been described as an effective and alternative method to percutaneous biliary drainage (PBD) in unresectable malignant biliary obstruction in case of endoscopic retrograde cholangiopancreatography (ERCP) failure. 18 Technical success rate of this technique has been described to be as high as 98% and common adverse events are most commonly bleeding (4.03%), bile leakage (4.03%), stent migration (2.68%) and cholangitis (2.43%). 19 On the other hand, compared to conventional percutaneous biliary drainage EABS is characterized by similar technical and clinical success rates and significantly lower complication rates compared with the external drainage group as demonstrated in a systematic review and meta-analysis of nine studies.…”

Covered self-expandable metallic stents versus plastic stents for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction

“…In addition, the risk of post-ERCP pancreatitis caused by traumatic papillary irritation was reduced in EUS-HGS. 8 However, EUS-HGS is still challenging because of the complexity of the procedure, risk of severe adverse events, including stent migration, and lack of dedicated devices. 9 In addition, There are several problems to be resolved before EUS-HGS can be optimized.…”

The Role of Endoscopic Ultrasound-guided Transmural Approach in the Management of Biliary Obstructions

“… 8 – 10 This provides an alternative to percutaneous or surgical drainage in cases of ERCP failure. 9 – 16 …”

“…[8][9][10] This provides an alternative to percutaneous or surgical drainage in cases of ERCP failure. [9][10][11][12][13][14][15][16] Despite numerous studies on the transmural approach to the biliary tract, which are currently available in the literature, many aspects of this technique remain unclear. This study aims to determine the role of the extra-anatomic transmural approach in biliary ET, by analyzing its effectiveness and safety, and the application of extra-anatomic endoscopic access to bile ducts in the treatment of patients with benign and malignant biliary obstruction.…”

“…In recent years, advanced endoscopic techniques have been developed based on the use of endoscopic ultrasonography (EUS), allowing for the implementation of an extra-anatomic transmural approach (access gained through the upper gastrointestinal wall) in biliary endotherapy (ET) 8–10. This provides an alternative to percutaneous or surgical drainage in cases of ERCP failure 9–16…”