Practical applications and learning curve for EUS-guided hepaticoenterostomy: results of a large single-center US retrospective analysis

Abstract

Background and study aims Endoscopic ultrasound-guided hepaticoenterostomy (EUS-HE) is an effective method of endoscopic biliary drainage in cases where endoscopic retrograde cholangiopancreatography has failed or is deemed impossible. Indications for EUS-HE have expanded, resulting in increased interest by endoscopists to learn the procedure; however, few data exist on breadth of application or experience needed to develop proficiency. We describe utilization of EUS-HE for biliary decompression at a large tertiary referral center along with procedural learning curve. Patients and methods Retrospective evaluation of 60 consecutive patients who underwent attempted EUS-HE by one endoscopist from February 2016 through June 2018. Procedures were divided into chronological and summative experience quartiles. We compared procedural success rate, procedural utilization, and procedure duration over time. Results Sixty patients underwent attempted EUS-HE during the study period: 35 with surgically altered anatomy, 23 with malignant biliary obstruction, 35 outpatients, 35 females; median age, 66 years. The procedure was technically successful in 53 patients. Success rates by summative experience quartile were 80 %, 80 %, 93.3 % and 100 % respectively. Beginning at patient number 40, the remaining cases had a success rate of 100 %. Utilization increased from eight cases in the first chronological quartile to 28 in the fourth. There was no significant reduction in procedure duration over time. Conclusion For an experienced endoscopist, EUS-HE could be performed effectively and safely after the experience of 40 cases. Limitations of this study include a single endoscopist and heterogeneous patient population with variable anatomy that may affect procedural success. Future studies should include data from multiple centers and endoscopists.

The role of endoscopic ultrasound guidance for biliary and pancreatic duct access and drainage to overcome the limitations of ERCP: a retrospective evaluation

“…This study was undertaken a decade after the adoption of EUS-DAD at our center. Operators were well past the learning curve of EUS-DAD, estimated at 30 -40 cases [31,32]. EUS-DAD was ingrained into our institutional treatment algorithms and referral pathways at the time of this evaluation.…”

“…This study was undertaken a decade after the adoption of EUS-DAD at our center. Operators were well past the learning curve of EUS-DAD, estimated at 30-40 cases[31,32]. EUS-DAD was ingrained into our institutional treatment algorithms and referral pathways at the time of evaluation.Our study is unique in that it includes all potential candidate patients, both intervention naïve and those with prior interventions, both biliary and pancreatic target ducts, and both benign and malignant indications.…”

Combined ERCP and transhepatic endoscopic ultrasound-guided stent placement for biliary drainage in malignant hilar obstruction: not too good to be true

“…There definitely is a steep learning curve, requiring about 40 cases to achieve competence. Interestingly, after the initial 40 cases, the success rate appears to be close to 100 % [9]. When EUS-BD becomes ingrained into ERCP practice, PTBD will effectively be relegated to a third-line ductal drainage option.…”

Malignant GOO: Are duodenal stenting and surgical gastrojejunostomy obsolete?

“…Even in the hands of experienced interventional endoscopists, there is undoubtedly a learning curve for advanced EUS procedures. For EUS-guided biliary drainage, around 30 to 40 cases are needed to achieve proficiency and more to achieve true mastery of the technique [20,21]. We have recently looked at the learning curve for EUS-GE using cumulative sum analysis and have found that around 25 cases are needed to achieve proficiency and 40 cases to achieve mastery [22].…”