Introduction

Endoscopic nasobiliary drainage is accompanied by a risk of accidental removal of the nasobiliary drainage (NBD) tube, especially through self-removal in elderly patients. UMIDAS NB stent (Olympus, Tokyo, Japan), hereafter referred to as UMIDAS, is an integrated plastic stent (PS) and NBD catheter system. In UMIDAS, the PS stays in the same place to maintain biliary drainage when the NBD tube is removed. Thus, UMIDAS has been developed to reduce endoscopic procedures following biliary drainage. We speculated that UMIDAS can be a safety net in accidental NBD tube deviation for acute cholangitis and obstructive jaundice. Therefore, we prospectively observed and reported the efficacy and disadvantages of UMIDAS (UMIN000047515).

Aims & Methods

From April to November 2022, we placed a UMIDAS NB stent in 30 patients with acute cholangitis or obstructive jaundice. We evaluated the plastic stent (PS) position at the time of accidental stent removal and before the planned endoscopic procedure. In addition, we studied the ratio of successful biliary drainage and complications based on the usage of UMIDAS.

Results

In this study, 19 planned NBD tube removals and 11 accidental removals were included. Among the 11 accidental removals, 4 were self-removal, 2 were accidental deviation to the intestine, and 5 were long period to next procedure. All 11 patients with accidental NBD tube removal showed a correct PS position after NBD tube removal. Of the 19 patients with planned NBD tube removal, 15 had a correct PS position, 2 had complete migrations into the common bile duct (Figure 5a), and 2 had incomplete migrations (the migration of the duodenal side flap only) before NBD tube removal. After removal, 13 patients had a correct PS position, 3 had complete migration of PS, and 3 had incomplete migration of PS. Of the 30 patients with UMIDAS, 24 (80%) had a correct PS position after NBD tube removal (27 (90%) if including incomplete migration). All patients with UMIDAS had successful biliary drainage, including patients with accidental removal of NBD, and had no complications.

Conclusion

The UMIDAS NB stent might be useful for biliary drainage in patients with a high risk of NBD tube self-removal.

Introduction

Hilar malignant biliary stricture, caused by malignant tumors, often leads to late diagnosis due to subtle initial symptoms, resulting in poor outcomes. Effective endoscopic interventions significantly improve quality of life and survival, yet often lead to post-operative complications like cholangitis.

Aims & Methods

This study aims to assess the effectiveness and safety of utilizing sequential nasobiliary tube cutting as an alternative to stent placement post-nasobiliary drainage in patients, specifically in mitigating post-operative cholangitis. Additionally, to identify risk factors associated with the development of post-operative cholangitis.
Patients diagnosed at Hangzhou First People's Hospital from January 2015 to January 2023 were divided into nasobiliary tube cutting group and conventional stent group. The former underwent nasobiliary drainage followed by tube cutting when stable, transitioning from external to internal drainage, while the latter received standard stent placement. Statistical analyses compared postoperative cholangitis incidence, drainage success, interventions, complications, and hospital stay, further examining risk factors for postoperative cholangitis.

Results

1. This study encompassed a total of 208 patients, with 103 in the nasobiliary tube cutting group and 105 in the conventional stent group. Postoperative cholangitis occurred in 40 patients, with 12 cases (11.7%) in the nasobiliary tube cutting group and 28 cases (26.7%) in the conventional stent group, showing a statistically significant difference between the two groups (P=0.006). The number of patients whose total bilirubin levels decreased by more than 50% within 7 days postoperatively was 50 (48.5%) in the nasobiliary tube cutting group and 29 (27.6%) in the conventional stent group, a statistically significant difference favoring the nasobiliary tube cutting group (P=0.002). There was no statistically significant difference in the overall drainage success rate between the two groups (P=0.207). Besides postoperative cholangitis, there were no statistically significant differences in other postoperative complications between the two groups (P>0.05). The postoperative hospital stay was longer for patients in the nasobiliary tube cutting group than those in the conventional stent group, with median durations of 10.0 (7.0, 14.0) days versus 7.0 (5.5, 12.5) days, respectively, a difference that was statistically significant (P=0.024).
2. Based on whether postoperative cholangitis occurred, the patients were further categorized into a postoperative cholangitis group (n=40) and a non-postoperative cholangitis group (n=168). Univariate analysis revealed significant differences between the postoperative cholangitis group and the non-postoperative cholangitis group in terms of gender (male), Bismuth-Corlette classification (Type IV), number of ERCP procedures (≥2 times), and re-intervention (P<0.05). Multivariate logistic regression analysis identified Bismuth-Corlette classification (Type IV) (OR=3.207, 95%CI: 1.253-8.210, P=0.015) as an independent risk factor for developing postoperative cholangitis.

Conclusion

For patients with hilar malignant biliary stricture, sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage can reduce the incidence of postoperative cholangitis and achieve early successful drainage, but it results in a prolonged postoperative hospital stay. Bismuth-Corlette classification (Type IV) is an independent risk factor for the development of postoperative cholangitis.

References

[1] VALLE J W, KELLEY R K, NERVI B, et al. Biliary tract cancer [J]. Lancet (London, England), 2021, 397(10272): 428-444.
[2] KHALAF N, EL-SERAG H B, ABRAMS H R, et al. Burden of Pancreatic Cancer: From Epidemiology to Practice [J]. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 2021, 19(5): 876-884.
[3] ELMUNZER B J, MARANKI J L, GóMEZ V, et al. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures [J]. Am J Gastroenterol, 2023, 118(3): 405-426.
[4] PIMPINELLI M, MAKAR M, KAHALEH M. Endoscopic management of benign and malignant hilar stricture [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2023, 35(4): 443-452.
[5] BANG J Y, HAWES R, VARADARAJULU S. Endoscopic biliary drainage for malignant distal biliary obstruction: Which is better - endoscopic retrograde cholangiopancreatography or endoscopic ultrasound? [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2022, 34(2): 317-324.
[6] IRISAWA A, MIYOSHI H, ITOI T, et al. Recent innovations in therapeutic endoscopy for pancreatobiliary diseases [J]. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society, 2020, 32(3): 309-315.

Disclosure

The authors declare that there are no conflicts of interest.

Introduction

Although biliary plastic stents (BPS) are frequently utilized in ERCP procedures, their effectiveness and associated complications can vary significantly. This study aimed to determine the risk factors associated with BPS patency within our patient population.

Aims & Methods

We conducted a retrospective analysis of patients who underwent endoscopic cholangiopancreatography (ERCP) at our facility from January 2021 to December 2022, excluding those with a malignant cause. The study included patients who underwent at least one ERCP reintervention within the past 23 months and received a biliary plastic stent during their initial ERCP

Results

Over a period of two years, our Gastroenterology department performed a total of 1354 procedures, with 1077 of these being for benign conditions. Of the 1077 benign cases, 212 (19.7%) required reintervention due to their etiology, and therefore had biliary plastic stents placed previously.
Out of a total of 212 subjects, 45% were male and had a mean age of 68.36±14.96 years. Among these subjects, choledocholithiasis was found to be the cause of obstruction in 81.1% of cases, common biliary duct stenosis in 9.5% of cases, chronic pancreatitis in 7% of cases, and other causes in 2.4% of cases.
The median interval between the initial procedure and the reintervention was 90 (1-1095) days. Acute cholangitis was the reason for reintervention in 32% (68/212) of the subjects, with 34% of them having Tokyo grade 3 cholangitis. In univariate regression analysis, the following factors were identified as independent predictors of cholangitis in patients with biliary plastic stents: total bilirubin levels, AST levels, ALT levels, number of days until reintervention, and CRP levels (p<0.05)

Conclusion

Within our cohort, 19.7% of patients required a reintervention for a benign condition following the initial placement of a biliary plastic stent. Of these patients, 32% experienced acute cholangitis as a reason for the reintervention. Our findings revealed that acute cholangitis in patients with biliary plastic stents was associated with days until reintervention, TGO levels, TGP levels, total bilirubin levels, and CRP levels.

Introduction

Endo-biliary radiofrequency ablation (RFA) is a novel minimally invasive intervention to treat stent occlusion in malignant biliary strictures1. Advances in oncological therapies have improved survival and tumour ingrowth into uncovered self-expanding metal stents (UcSEMS) is common and strategies to manage this are limited2. We aimed to determine the clinical outcomes of endo-biliary RFA using ELRATM probe (Taewoong) in patients with UcSEMS occlusion.

Aims & Methods

Retrospective data was collected from February 2020 to March 2023 at St Thomas’ Hospital.

Results

28 endo-biliary RFA’s were performed in 12 patients for occluded UcSEMS over this period, delivered by 3 operators. Demographics are shown in table 1. Excluding two recent cases, 60% required multiple RFA interventions. The median number of RFA’s was 2, with one patient requiring 9 sessions. One patient was excluded as there was significant parenchymal disease in addition to UcSEMS occlusion and despite RFA, there was progression in liver metastasis. For patients with bilirubin monitoring post RFA, 11 (100%) procedures resulted in a reduction in bilirubin between 1-4 weeks. The average reduction in bilirubin was 61.4% (6/11 patients) at week 1 and 77.4% (9/11 patients) at week 2-4. Excluding 2 recent cases, survival was 90 % at 30 days post procedure, and 70% at 90 days. Survival was 100% at 90 days for cholangiocarcinoma. The patient requiring 9 sessions (not on chemotherapy), survived for 18 months with significantly improved quality of life. There were no recorded complications. Technical difficulties were encountered in 2 cases due to impedance in bilobar stents with a Y configuration due to contact of the probe with metal at the hilum.
Table 1: Demographics
M:F 7:5
Mean age 71
Performance status 0-2
Malignancy Cholangiocarcinoma=5, Pancreatic cancer=4, gall bladder=1, Hepatocellular carcinoma=1,metastatic breast cancer=1

Conclusion

Endo-biliary RFA had good technical and clinical success with measurable reduction in bilirubin in patients with UcSEMS occlusion without any complications in our cohort. It is difficult to say if survival is purely due to biliary drainage or if there is an anti-tumour effect with RFA, especially given the 100% survival at 3 months in patients with cholangiocarcinoma. Additional data from randomised controlled trials is required to assess the role of RFA in malignant strictures.

References

Management of malignant biliary obstruction. Gut 64, A216–A217 (2015).
2. Steel, A. W. et al. Endoscopically applied radiofrequency ablation appears to be safe in the treatment of malignant biliary obstruction. (2011) doi:10.1016/j.gie.2010.09.031.

Disclosure

Nothing to disclose

Introduction

Perforation is one of the most serious complications in endoscopic retrograde cholangiopancreatography (ERCP). Conventional non-surgical treatment, including intravenous antibiotics with nothing per oral(NPO) and traditional bile drainage (plastic ERBD, PTGBD, PTBD), is generally approved treatment for the ERCP-related Stapfer’s type ll perforation (perivaterian type). The biliary covered metal stent placement has recently been reported to have favorable outcomes in ERCP-related type ll perforation.

Aims & Methods

We aimed to compare the outcomes of conventional treatment and biliary covered metal stent insertion in patients with Stapfer’s type II perforation. ​The medical records of patients who underwent ERCP at Kyungpook National University Hospital in Daegu from 2011 through 2022 were retrospectively reviewed.

Results

8,402 ERCP procedures were conducted in our hospital. 66 ERCP-related perforations (0.78%) were identified with 47 patients (71.2%) had type II perforations. 34 patients received conventional treatments, 13 patients received biliary covered metal stent insertions. There were also no significant differences in clinical success rate (97.1% vs 92.3%, p=0.481), hospital stay (15.53±11.35 vs. 9.46±5.97 days, p=0.227), and NPO times (3.79±3.00 vs. 5.42±3.40 days, p=0.127). The conventional bile drainage group took shorter time for ERCP than SEMS group (12.62±6.315 vs. 18.46±11.16 minutes, p=0.028).

Conclusion

The biliary covered metal stent insertion did not improve patient’ outcomes when compared with the conventional treatment method in ERCP-related type II perforations. Conventional treatment is sufficient for management of ERCP-related type II small sized perforations.

Introduction

Endoscopic ultrasound-guided biliary drainage (EUS – BD) has become widely accepted over the past several years for complicated biliary drainage when conventional endoscopic retrograde cholagiopancreatography is not successful or feasible due to variety of constrains. The success rate of the procedure is between 90% an 97% and the complication rate is less than 10%.

Aims & Methods

The aim of the study is to evaluate the safety and efficacy of EUS-BD performed in our unit while assessing the risk factors associated with the procedure.
We performed retrospective analysis of a prospective data base from March 2020 to October 2023. The patients underwent EUS – BD using linear scope (Fujifilm EG – 580UT). Several procedures are possible. The procedure was tailored to individual patient’s anatomy.

Results

We identified 140 patients who underwent EUS-BD during the study period ( men- 75, women- 65) – 130 (92.8%) with malignant and 10 (7.1%) with benign disease. Gender distribution shows higher rate of postprocedural complications in men ( 29,7% vs 21,5%), nevertheless there is no statistically significant correlation between gender and complication rate. The medium age of the patients was 66.3 years (38 years – 92 years). No statistically significant correlation was found between age, presence of arterial hypertension, diabetes mellitus and adverse events.
We analyzed the different therapeutic modalities including EUS - CDS (n = 20), EUS - HGS (n = 88), antegrade stenting (n = 12) and rendezvous (n = 13), hepaticojejunostomy (n = 5), cholecystogastrostomy and -duodenostomy (n = 2). We found no statistically significant correlation between the type of technical modality and the incidence of peri- and post-procedural complications.
The technical success was 96.6% (n = 137). Mean duration of the procedure was 42.15 min. (10 min. – 170min.). Mean hospital stay was 5 days (2 days – 10 days ). Adverse events were detected in 38 patients (27.1%). The various complications that have been reported were classified into periprocedural and postprocedural:

• Periprocedural adverse events were detected in 7 (5%) patients: 2 (1.4%) with bleeding, 2 (1.4%) with stent migration, 3 (2,1%) with loss of access.
• Postprocedural complications are deteced in 29 (20,7%) and we divided into:

1. Early (up to 7 days after procedure) – n = 21 (15%) of them 13 (9,3%) with cholangitis, 3 (2,1%) with abdominal pain, 1 (0,7%) with bleeding, 2 (1,4%) with pancreatitis, 1 (0,7%) with pneumoperitoneum and 1 (0,7%) patient with biloma.
2. Late (a week after the procedure) – n = 8 (5,7%) with cholangitis.

• There were 2 deaths related to the procedure (1.4%) in patients with advanced oncologic disease.

Conclusion

EUS-BD is effective tool for biliary drainage both in naïve patients and those with altered biliary anatomy. Along with the possibility of emergency PTBD, it has favourable technical and clinical success rate and safety profile and therefore the potential to shift the current paradigms that define management of complicated biliary obstruction.

References

1. Hatamaru K, Kitano M. EUS-guided biliary drainage for difficult cannulation. Endosc Ultrasound 2019;8(Suppl 1):S67–S71
2. Baars JE, Kaffes AJ, Saxena P. EUS-guided biliary drainage: a comprehensive review of the literature. Endosc Ultrasound 2018;7(01):4–9
3. Kakked G, Salameh H, Cheesman AR, Kumta NA, Nagula S, DiMaio CJ. Primary EUS-guided biliary drainage versus ERCP drainage for the management of malignant biliary obstruction: a systematic review and meta-analysis. Endosc Ultrasound 2020;9(05): 298–307
4. Khan MA, Akbar A, Baron TH, et al. Endoscopic ultrasound-guided biliary drainage: a systematic review and meta-analysis. Dig Dis Sci 2016;61(03):684–703
5. Giri S, Mohan BP, Jearth V, Kale A, Angadi S, Afzalpurkar S, Harindranath S, Sundaram S. Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis. Gastrointest Endosc. 2023 Oct;98(4):515-523
6. van der Merwe SW, van Wanrooij RLJ, Bronswijk M, et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2022;54:185-205
7. Ogura T, Higuchi K. Endoscopic ultrasound-guided hepaticogastrostomy: technical review and tips to prevent adverse events. Gut Liver 2021;15(02):196–205
8. Ogura T, Higuchi K. Technical review of developments in endoscopic ultrasound-guided hepaticogastrostomy. Clin Endosc 2021;54(05):651–659

Disclosure

Also presented on ESGE DAYS 2024

Introduction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a minimally invasive and promising alternative to percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in managing malignant biliary obstruction. Different techniques are available such as choledocoduodenostomy (CDS), gallbladder drainage (GBD) and hepaticogastrostomy HGS). All have been shown to be safe and effective techniques, but which is the most suitable and effective approach is still unknown.

Aims & Methods

We aim to compare the three techniques available in terms of technical success and clinical success, and to assess the adverse events related to the different procedures. Single center retrospective analysis of all consecutive cases of CDS, GBD and HGS acceding to the Therapeutic Endoscopy Unit of Fondazione Policlinico Universitario Campus Bio-Medico of Rome. Data about patients and procedures were collected. Technical success was defined as successful biliary drainage with stent placement. Clinical success was defined as a decrease in total bilirubin level by ⩾30% within 7 days of EUS-BD.

Results

From April 2016 to December 2024 101 patients were included (47.5% male, mean age 74.6 years old), all with malignant biliary obstruction. 52,5% of the subjects (53/101) underwent EUS-CDS, 22,7 % (23/101) underwent EUS-GBD and 24,75% (25/101) underwent EUS-HGS. In 35/101 (34,65%) duodenal stenosis was observed. A total of 7 patients had altered anatomy. The mean procedure time was 26 ± 15,7 minutes. Overall technical success was 93%, 48/53 (90,5%) in the CDS group, 23/23 (100%) in the GBD group and 23/25 (92%) in the HGS group. Overall clinical success was achieved in 57/79 (72%), 29/38 (76,3%) in the CDS group, 12/20 (60%) in the GBD group and 16/21 (76,1%) in the HGS group. When considering a reduction in bilirubin level ⩾50%, the overall clinical success was lower (55%). Adverse events occurred in 6/101 (5,9%) of the patients, 3/53 (5,6%) in the CDS group, 0/23 in the GBD group and 3/25 (12%) in the HGS group. There was no difference in terms of sex, age, altered anatomy, presence of duodenal stenosis and the EUS technique performed. The mean time of the procedure was higher in the HGS group, with a difference statistically significant (CDS=22,87±14,78 min, GBD=26±15,73 min, HGS=41±16,09 min, p=0,005). No difference was observed in terms of technical and clinical success, and adverse events between the three procedures. However, if the reduction in bilirubin level ⩾50% cut-off was used, the HGS was the procedure with the highest rate of clinical success (CDS 59,5% vs GBD 25% vs HGS 76%, p=0,003).

Conclusion

EUS-BD is a safe procedure with high technical and clinical success rate and it s a valid alternative for managing malignant biliary obstruction in high volumes centers. No differences are described between the three approaches. However HGS seems to reduce bilirubin levels more quickly, with longer procedure time.