Introduction

Endoscopic ultrasonography–guided rendezvous technique (EUS-RV) has been reported to be useful as a salvage method in cases of difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). Having said that, needle-knife precut (including transpancreatic sphincterotomy) is often selected over EUS-RV. However, it is associated with adverse events such as retroperitoneal perforation, retroperitonitis, and papillary hemorrhage. On the other hand, EUS-RV has been reported to afford a higher success rate and lower incidence of adverse events. Nevertheless, few studies have compared the effectiveness of EUS-RV and the precut method.

Aims & Methods

To compare the outcomes of EUS-RV and the precut method in cases of difficult cannulation of the common bile duct due to stones.
From January 2018 to September 2022, 735 patients with a naive papilla with common bile duct stones underwent ERCP excluding post-reconstruction intestinal tract (excluding the Billroth-I method). Forty-three patients underwent salvage cannulation. EUS-RV and the precut method were attempted in 14 and 29 cases, respectively. There was no case in which the precut method and EUS-RV were performed in a single session. All patients received standard post-ERCP pancreatitis prophylaxis, and the success rates of the technique, adverse event rates, and procedure time were documented.

Results

The technical success rates of biliary cannulation via EUS-RV and the precut method were 83% and 79%, respectively. The corresponding adverse event rates were 13% and 28%. The adverse events noted were as follows: two cases of posterior hemorrhage and one of pancreatitis in patients who underwent EUS-RV and three cases of pancreatitis and one of posterior hemorrhage among patients in whom the precut method was performed. The median times from starting the usual cannulation technique to the decision to switch to the salvage method were 17 and 20 min, respectively, among patients in whom EUS-RV and precut method were attempted. The corresponding median times from the decision to switch to the salvage method to successful biliary cannulation (or quitting in cases of failure) were 20 and 26 min (p = 0.02).

Conclusion

EUS-RV tended to have a higher success rate and cause fewer adverse events than the precut method. However, the associated procedure time was significantly longer, partly because it included the time required to replace the endoscope twice. The findings suggest that EUS-RV can be an option in cases in which the usual cannulation technique has failed, because the associated technical success and adverse event rates are similar.

References

Mallery, 2004 ;
Kim, 2010 ;
Iwashita, 2012 ;
Dhir, 2013 ;
Kawakubo, 2013

Introduction

Endoscopic retrograde cholangiopancreatography /ERCP/ is the standard technique in the treatment of unresectable malignant biliary obstruction/MBO/, unfortunately, a failure rate of 3% up to 12 % and a rate of complications up to 6,85% have been reported in the literature. Endoscopic ultrasound-guided biliary drainage/EUS – BD/ is a feasible alternative for biliary drainage, applicable especially with surgically altered anatomy. With several techniques available, hepaticogastrostomy /EUS - HGS/ and choledochoduodenostomy/EUS - CDS/ are most commonly performed amongst them.

Aims & Methods

To compare the most commonly used techniques for endoscopic ultrasound-guided biliary drainage in terms of efficacy and safety.
Methods:Retrospective analysis of a prospective database of patients undergoing EUS -BD in a single tertiary referral center. EUS–BD was performed after the failure of ERCP or as a first choice of drainage procedure in patients with altered anatomy. 102 patients were included in the EUS-HGS group 94,12%(n=96) with malignant biliary obstruction and 5.12%(n=6) with benign underlying disease. Of 24 patients included in the EUS–CDS group 95,83% (n=23) had underlying malignancy against one patient with benign disease.

Results

Considering the application of EUS – BD as a first choice of drainage procedure for patients with surgically altered anatomy we had 46 patients in the HGS group (45.1%) against 16.67%(n=4) for the CDS group. In 56/44,44%/ cases EUS BD was performed during the same session after unsuccessful cannulation. Evaluating results in terms of technical success rate, defined as successful stent placement – we found a 98,04 % success rate for the EUS-HGS group and 95,83% in the EUS–CDS group. We defined clinical success as a drop in the bilirubin levels by one-half in the first week following the procedure. The results between the two groups were not significantly different - 80.46% for the HGS against 80,95% for the CBS group. Concerning adverse events during the procedure, we found a ratio of 7.84% for the patients undergone HGS and 4,76% for EUS – CDS with no significant difference. The most common AE found was proximal stent misdeployment/n=3/. All of the events were managed either conservatively or during the same session with the placement of fully covered SEMS. Concerning early AE /during the first 7 days / we experienced 14,71% early adverse events in the HGS group/n=15/ and 16,67% /n=4/ in the CDS group with most common event postprocedure infection with no significant difference.

Conclusion

The two most common transluminal techniques for EUS biliary drainage - HGS and CDS are a promising tool with comparable technical and clinical success rates, adverse events, and overall survival. Both procedures are valid alternatives after failed ERCP or as a first step especially in patients with surgically altered anatomy.

Introduction

Laparoscopic cholecystectomy (LC) remains the standard treatment for acute cholecystitis; however, it is not always suitable for patients who are poor candidates for surgery. Moreover, the rate of complications is approximately 10-30% and the mortality rate is approximately 1-2 %, which is not low. Percutaneous transhepatic gallbladder drainage (PTGBD) is recommended as conservative treatment, but the average hospital stay for PTGBD is considerably longer than that for LC especially in Japan. Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been reported as an alternative treatment for inoperable cholecystitis. However, it has rarely been reported as a preoperative gallbladder drainage because the stent is commonly placed between the gallbladder and duodenum. We have developed an EUS-GBD kit for preoperative gallbladder drainage and have verified the function of it in live pigs for clinical introduction. This kit consists of anchors to fix between the gallbladder and stomach walls and the drainage tube.

Aims & Methods

The purpose of this study is to investigate the feasibility of LC after EUS-GBD with our novel drainage kit. Between May 2019 and March 2024, EUS-GBD with the novel drainage kit was performed on 52 live pigs. In twelve of them, LC was performed 2-9 weeks after EUS-GBD. We investigated the feasibility of LC, the rate of conversion to open cholecystectomy, and the complications.

Results

LC was successfully performed in all cases. In seven cases, the anchors and drainage tube were endoscopically removed just before LC. In five cases, they were not removed before LC, and the gallbladder was removed along with the fistula including a part of the stomach. In all cases, there were no conversion to open cholecystectomy and no complications.

Conclusion

Laparoscopic cholecystectomy after EUS-GBD using our novel drainage kit is feasible in live pigs, and we are currently verifying it though clinical trials involving humans.

Disclosure

I hold a 71% ownership stake in KOEDA Inc.

Introduction

During endoscopic retrograde cholangiopancreatography (ERCP) for biliary indication, difficult biliary cannulation with an unintended access to the main pancreatic duct (PD) increases the risk of post-ERCP pancreatitis (PEP). Both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed.

Aims & Methods

The purpose of this prospective, randomized, controlled trial is to compare the technical success and adverse events (AEs) rate of these techniques.

Results

Conclusion

In difficult biliary cannulation, TPBS demonstrated a higher success rate and similar safety profile compared with DGW. there was no difference in PEP rate between TPBS and DGW techniques. TPBS is a good alternative in cases of unintended PD cannulation of difficult cannulation.

Introduction

Precut techniques provide an alternative approach for biliary cannulation during ERCP. While traditionally considered high-risk and typically reserved for high-volume centers, recent evidence supports the safety and efficacy of early precut techniques when performed by experienced endoscopists. However, data on the safety of precut techniques in the outpatient setting remain limited, particularly in comparison to standard sphincterotomy.

Aims & Methods

We conducted a retrospective analysis of all outpatient ERCP procedures performed at our institution between 2020 and 2024. A total of 304 cases were reviewed. Patients were divided into two groups: Group A, who underwent standard sphincterotomy, and Group B, who required precut techniques following failed standard cannulation attempts.

Results

A total of 159 outpatient ERCPs involving naïve papillae were included: 122 in Group A and 37 in Group B. There was no significant difference in baseline characteristics and indications for ERCP between the 2 groups. Overall cannulation success rate was 97.5% (n=155/159), reaching 89.2% (n=33/37) in the pre-cut group. There was an overall post-procedure complication rate of 6.9% (n=11/159): 7.4% (n=9/122) of patients in Group A and 5.4% (2/37) in Group B, with no significant difference between groups (p= 0.860).

Conclusion

In our outpatient ERCP cohort, precut techniques demonstrated a favorable safety profile and comparable outcomes to standard sphincterotomy. These findings support the selective use of precut methods in the outpatient setting.

References

1) Moreira M, Tarrio I, Andrade AJ, Araújo T, Fernandes JSS, Canena J, Lopes L. Standard Cannulation versus Fistulotomy for Biliary Access in Endoscopic Retrograde Cholangiopancreatography: Should We Expect the Same Success when Treating Choledocholithiasis? GE Port J Gastroenterol. 2024 Feb 14;31(6):401-407. doi: 10.1159/000536398. PMID: 39633909; PMCID: PMC11614427.
2) Jeurnink SM, Poley JW, Steyerberg EW, Kuipers EJ, Siersema PD. ERCP as an outpatient treatment: a review. Gastrointest Endosc. 2008 Jul;68(1):118-23. doi: 10.1016/j.gie.2007.11.035. Epub 2008 Mar 4. PMID: 18308308.

Introduction

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has gained popularity as an alternative to percutaneous biliary drainage for patients in whom endoscopic retrograde cholangiopancreatography (ERCP) has failed. Several studies have compared EUS-CDS versus ERCP for primary biliary decompression for distal malignant biliary obstruction (MBO). These studies have reported variable results and were limited because of small sample sizes.

Aims & Methods

The aim of this study was to compare EUS-CDS versus ERCP for primary biliary decompression in distal MBO. A prospective randomized controlled study conducted on patients with unresectable distal MBO. Enrolled patients were randomized to EUS-CDS or ERCP. Technical success was defined as the placement of the metal stent across the stricture site via the papilla (ERCP) or across the duodenum (EUS-CDS), along with the flow of the bile through the stent. Clinical success was defined as reduction of total serum bilirubin levels to less than half of the pretreatment level within 2 weeks. Patients were hospitalized and observed for early complications in the first 2 days. Laboratory investigation were repeated in regular out patients visits at 2, 4, 12 and 24 weeks or until death.

Results

From May 2021 to December 2022, a total of 62 patients were enrolled (28 EUS-CDS and 34 ERCP) and 54 completed the study (4 patients in each group have dropped out due to non-procedural related mortality within 2 weeks). There was 32 males and 22 females. Their median age was 64 years (45-82). Technical success rates were similar in both groups (100%). Clinical success rates were 95.8% (23/24) in EUS-CDS group and 93.3% (28/30) in ERCP group. There was no statistically significant difference in the median procedure time between EUS-CDS group (13 (IQR 7-32) mins) and ERCP group (16 (IQR 6-75) mins) (p=0.57). The rate of overall adverse events was not statistically significant between both groups (EUS-CDS 8.3%, ERCP 3.3%; p=0.45). In EUS-CDS group, post procedural biliary peritonitis was observed in 1 patient and post procedural bleeding that required endoscopic intervention with Argon plasma coagulation was observed in 1 patient. Post procedural mild pancreatitis was observed in 1 patient in ERCP group. For late adverse events, stent patency was similar, and none required reintervention in both groups.

Conclusion

EUS-CDS and ERCP had comparable levels of efficacy and safety for the primary palliation of unresectable distal MBO based on rates of technical, clinical success and over all adverse events.