Introduction

If the diameter of the intrahepatic bile duct is much less dilated, bile duct puncture with a 19G needle can be challenging during EUS-guided transhepatic biliary drainage (EUS-THBD). These characteristics can decrease the difficulty of bile duct puncture, but use of a 22G needle is less feasible because of poor visibility, maneuverability, and stiffness of conventional 0.018-inch guidewire. A novel, improved 0.018-inch guidewire and dilation devices have recently become available.

Aims & Methods

We conducted a prospective study to evaluate the technical feasibility and safety of EUS-BD in patients with insufficient bile duct dilatation using a 22G needle and the new 0.018-inch guidewire. A 22G needle is used as the puncture needle for intrahepatic bile ducts of diameter <1.5 mm, and a 19G needle is selected for diameters ³1.5 mm. As the primary endpoint of the study, the technical success rate of EUS-THBD using a 22G needle with the novel 0.018-inch guidewire was evaluated in patients with insufficient dilation of the intrahepatic bile duct.

Results

A total of 63 patients who required EUS-THBD were enrolled (22G needle group, n=30; 19G needle group, n=33). Technical success was obtained in all patients in the 19G needle group. In the 22G needle group, technical failure occurred in two patients due to non-identification of the intrahepatic bile duct on EUS (technical success rate, 93.1%), and puncture of the bile duct itself was not performed in these patients. Mean procedure time was similar between the groups. Adverse events were observed in 10.3% (3/30) of patients in the 22G needle group, and in 24.2% (8/33) in the 19G needle group.

Conclusion

In conclusion, use of a 22G needle with a novel 0.018-inch guidewire was comparable to a 19G needle with 0.025-inch guidewire, even in the case of insufficient intrahepatic bile duct dilatation.

Disclosure

None

Introduction

Metal (MS) or plastic stents (PS) are used for preoperative biliary drainage (PBD) in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing neoadjuvant chemotherapy (NAC) or chemoradiotherapy (NACRT). However, there are no large studies comparing postoperative adverse events(AEs) and postoperative long-term outcomes between patients who received MS and those who received PS for PBD.

Aims & Methods

This multicenter retrospective study compared the safety and efficacy of PBD using MS and PS, including surgery-related adverse events and other clinical outcomes.
This study enrolled patients with resectable or borderline resectable PDAC requiring NAC or NACRT who underwent PBD with MS or PS at 17 tertiary care hospitals in Japan between January 2016 and December 2021. Clinical outcomes, including the incidence of recurrent biliary obstruction (RBO), time to RBO, time from stent placement to surgery, postoperative hospital stay, incidence of postoperative adverse events, and postoperative overall survival, were retrospectively analyzed.

Results

Among the 308 patients with PDAC who received PBD before NAC or NACRT, 251 subsequently underwent pancreatic resection. Of these 251 patients, 122 (48.6%) had PBD with MS, while 129 (51.4%) had PBD with PS. Because there were significant differences in baseline characteristics between both groups, propensity score matching was performed, resulting in 84 matched pairs. RBO occurred significantly less frequently in the MS group than in the PS group (11.9% vs. 59.5%, p < 0.001). Time to RBO is significantly longer in the MS group than in the PS group (median 353 days vs. 74 days, p < 0.001). The MS group also showed significantly reduced time to surgery from stent placement (median 95 days vs. 112 days, p = 0.010) and shorter postoperative hospital stays (median 17 days vs. 20 days, p = 0.025). Although postoperative AEs occurred less often in the MS group (19.1% vs. 29.8%), the difference was not statistically significant (p = 0.106). In both univariate and multivariate models, RBO was identified as the sole independent factor associated with postoperative AEs (odds ratio: 2.36, p = 0.019). However, the type of stent used was not significantly associated with the occurrence of postoperative AEs. Notably, the incidence of postoperative pancreatic fistula was significantly higher in patients who developed RBO compared to those who did not (16.7% vs. 5.6%, p = 0.027).

Conclusion

For patients with PDAC undergoing NAC or NACRT, MS placement is preferable to PS placement for PBD. MS placement was associated with a lower incidence of RBO and need for re-intervention, as well as a shorter perioperative hospital stay. Given the reduced frequency of RBO, which is an established risk factor for postoperative AE, MS placement is recommended for PBD in this setting.

Introduction

To prevent stent migration during EUS-HGS, intra-scope channel release technique is important, but are unfamiliar to non-expert hands. The self-expandable metal stent (SEMS) is an additional factor to prevent stent migration. However, no comparative studies of laser-cut and braided types during EUS-HGS have been reported.

Aims & Methods

The aim of this study was to compare the distance between the intrahepatic bile duct and stomach wall after EUS-HGS among laser-cut- and braided-type SEMS. To evaluate stent anchoring function, we measured the distance between the hepatic parenchyma and stomach wall before EUS-HGS, one day after EUS-HGS, and 7 days after EUS-HGS.　Also, propensity score matching was performed to create a propensity score for using Laser cut type group and Braided group with a logistic regression model.

Results

A total 144 patients were enrolled in this study. Among them, 24 patients underwent EUS-HGS using a laser-cut-type SEMS, and 118 patients underwent EUS-HGS using a braided-type SEMS. EUS-HGS using the laser-cut-type SEMS was mainly performed by non-expert endoscopists (n=21). However, EUS-HGS using braided-type SEMS was mainly performed by expert endoscopists (n=98), showing a significant difference. The distance after 1 day was significantly shorter with the laser-cut-type group (2.91 ± 1.88 mm) compared with the braided-type group (8.19 ± 6.07 mm). In addition, this distance remained significantly shorter in the laser-cut type group compared with the braided-type group after 7 days.　Although these results were similar after propensity score matching analysis, the distance between hepatic parenchyma and stomach after 7 days was increased 4mm compared with the distance after 1 day in Braided group. On the other hand, in Laser cut type group, the distance after 1 day and 7 days was almost same.

Conclusion

In conclusion, EUS-HGS using a laser-cut-type SEMS may be safe to prevent stent migration, even in non-expert hands, compared with a braided-type SEMS, although a randomized trial is warranted.

Disclosure

None

Introduction

Balloon dilation and plastic stent deployment have been performed as hepaticojejunostomy stricture (HJS) treatment techniques by PTBD or under DB-ERCP guidance. Although these techniques have shown favorable clinical results, the treatment period can be long because stent deployment is required. In addition, HJS may recur even after treatment because the scar tissue itself remains. To overcome these challenges, we developed an transluminal antegrade piecemeal dilation technique (TAPD) for treating HJS. The aim of this study was to evaluate the technical feasibility and safety of this technique in terms of the pre- and post-cholangioscopic findings.

Aims & Methods

This retrospective study included consecutive patients who were complicated with symptomatic HJS between November and February 2022. The primary outcome of this study was the technical success rate of TAPD using a drill dilator. Technical success was defined as resolution of the HJS, based on the cholangioscopic findings. The secondary outcome was adverse events associated with TAPD such as bleeding or perforation.

Results

TAPD was attempted at around 11 days after EUS-HGS in 19 patients. Among the 19 patients, passage of the guidewire across the HJS into the intestine was unsuccessful in 4 patients, and the technical success rate of this procedure was 78.9%. TAPD was successful in all 15 patients in whom passage of the guidewire was achieved. After TAPD, cholangioscopy identified no bleeding or perforation in any patient. During the follow-up period, no recurrence of HJS was observed in any patient who underwent TAPD.

Conclusion

In conclusion, TAPD appears to be technically feasible and safe. Although it is necessary to conduct a randomized trial in comparison with other methods, with long-term follow up, TAPD may be a useful option for the treatment of HJS.