Introduction

Biliodigestive diversions are surgical procedures aimed at bypassing obstructions or restoring the flow of bile from the liver to the digestive tract. These procedures are commonly performed in patients with biliary tract obstructions caused by conditions such as tumors, strictures, or stones. By creating an alternate pathway for bile drainage, biliodigestive diversions help alleviate symptoms and prevent complications associated with biliary obstruction, improving the patient's quality of life and overall prognosis. There are various techniques for biliodigestive diversions, including hepaticojejunostomy, hepaticogastrostomy, and choledochoduodenostomy, each tailored to the specific needs and anatomical considerations of the patient.

Aims & Methods

Aims: Compare the efficacy and safety of biliodigestive diversion procedures, hepaticogastrostomy and choledochoduodenostomy, in patients with biliary tract obstructions.
Methods: Restrospective comparative study in patients with biliary tract obstructions undergoing either hepaticogastrostomy or choledochoduodenostomy at Centro Medico Nacional 20 de Noviembre will be included in the study from 2018- 2024.

Results

We evaluated 65 patients in total, median age 65 years, 44% were female, we had 3 biliodigestive procedures: Coledocoduthdenostomy 50%, Hepaticogastrostomy 28.1% and Rendez-vous 12.5%, the type of prothesis were 10x8 30%, 8x8 10%, Hot Axius in 5%, 10x6 16%, technical success reported was 87.5% and clinical success was 89.1, Five patients experienced complications, with peritonitis being the most frequent, followed by bleeding. These findings underscore the importance of vigilant post-procedural monitoring and prompt management of complications to ensure optimal patient outcomes.

Conclusion

These results are encouraging and suggest that both choledochoduodenostomy and hepaticogastrostomy are effective procedures for addressing biliary obstructions in this patient cohort. Additional Considerations that we want to mention, It's important to note that both technical and clinical success are important indicators of procedure efficacy and safety and that further analysis would be helpful to explore any association between the type of procedure performed and long-term outcomes, such as patency duration and patient quality of life.Overall, these results provide valuable insights into the practice of endoscopic ultrasound-guided biliodigestive diversion in Mexico and may serve as a basis for future research and clinical practice in this field.

References

Arvanitakis, M., Gkolfakis, P., Despott, E. J., Ballarin, A., Beyna, T., Boeykens, K., Elbe, P., Gisbertz, I., Hoyois, A., Mosteanu, O., Sanders, D. S., Schmidt, P. T., Schneider, S. M., & van Hooft, J. E. (2021). Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indicationsEuropean Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy, 53(1), 81–92. https://doi.org/10.1055/a-1303-7449
Oh, D., Han, S. Y., Lee, S. H., Kim, S. H., Paik, W. H., Chon, H. K., Song, T. J., Park, S. W., & Cho, J. H. (2024). Comparison of long-term outcomes of endoscopic ultrasound-guided hepaticogastrostomy and choledochoduodenostomy for distal malignant biliary obstruction: a multicenter retrospective study. Therapeutic Advances in Gastroenterology, 17. https://doi.org/10.1177/17562848241239551
Gkolfakis, P., Arvanitakis, M., Despott, E. J., Ballarin, A., Beyna, T., Boeykens, K., Elbe, P., Gisbertz, I., Hoyois, A., Mosteanu, O., Sanders, D. S., Schmidt, P. T., Schneider, S. M., & van Hooft, J. E. (2021). Endoscopic management of enteral tubes in adult patients - Part 2: Peri- And post-procedural managementEuropean Society of Gastrointestinal Endoscopy (ESGE) Guideline. In Endoscopy (Vol. 53, Issue 2, pp. 178–195). Georg Thieme Verlag. https://doi.org/10.1055/a-1331-8080

Introduction

ERCP is the cornerstone for managing biliary and pancreatic duct diseases. However, performing in patients with surgically altered anatomy poses significant challenges. Traditional ERCP techniques often fail in these cases due to difficulties in accessing the papilla. This has led to the development of alternative techniques like enteroscopy-assisted ERCP (e-ERCP) and endoscopic ultrasound-directed transenteric ERCP (EDEE).
e-ERCP while it can be successful, is technically demanding, time-consuming, and associated with a higher risk of complications while EDEE involves using EUS guidance to create a temporary anastomosis between the stomach and the intestinal segment containing the papilla. EDEE offers a more direct and stable route to the biliary tree, However, it requires specialized equipment (lumen-apposing stents) and expertise.

Aims & Methods

Retrospective observational, patients undergoing EDEE or e-ERCP at the CMN 20 de Noviembre between 2018-2024

Results

This study compared two endoscopic procedures, e-ERCP and EDEE, for accessing the biliary tract in patients with altered anatomy. The average age of the patients was 48 years, with a standard deviation of 14 years, and 61% were women. Most patients (81%) underwent e-ERCP, while only 9% underwent EDEE. Regarding the success of the procedure, e-ERCP had a technical success rate of 87%, endoscopic success rate of 93%, and clinical success rate of 75%. On the other hand, EDEE, although performed in a small number of patients, showed a 100% success rate in all three categories. Adverse events occurred in 5% of patients. 72% of patients had altered anatomy due to a pancreaticoduodenectomy, and 90% had a Roux-en-Y hepaticojejunostomy. In addition, dilations were performed in 72% of patients, stents were placed in 17%, and sphincterotomy or precut was performed in 17%.

Conclusion

The average cost of EDEE was 120,000 pesos (6,000 USD), while that of e-ERCP was 40,000 pesos (2,000 USD). Despite the difference in cost, EDEE showed a 100% success rate in this study, suggesting that it could be a cost-effective option for patients with altered anatomy in whom e-ERCP is not feasible or has failed. However, a cost-effectiveness analysis, considering the cost of the procedure divided by the proportion of clinical success, showed that e-ERCP was more cost-effective than EDEE.
Studies with a larger number of patients are needed to confirm these findings and to evaluate the safety and cost-effectiveness of EDEE compared to e-ERCP. This study is limited by the small number of patients with EDEE and the lack of information on the type of complications, the duration of the procedures, and long-term survival. It is recommended to expand the research with more patients and to perform a statistical analysis to formally compare the two procedures.

References

1. Khashab M. A. (2019). Endoscopic ultrasound-directed transenteric ERCP (EDEE) in patients with postsurgical anatomy - novel but challenging. Endoscopy, 51(12), 1119–1120. https://doi.org/10.1055/a-0958-2323
2. Ichkhanian, Y., Yang, J., James, T. W., Baron, T. H., Irani, S., Nasr, J., Sharaiha, R. Z., Law, R., Wannhoff, A., & Khashab, M. A. (2020). EUS-directed transenteric ERCP in non-Roux-en-Y gastric bypass surgical anatomy patients (with video). Gastrointestinal endoscopy, 91(5), 1188–1194.e2. https://doi.org/10.1016/j.gie.2019.12.043

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

Pathological diagnosis of biliary lesions is usually performed via a transpapillary approach; however, its diagnostic yield is insufficient. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) presents a technically challenging alternative, with concerns about bile leak and tumor cell seeding, resulting in scarce data.

Aims & Methods

In this study, we evaluated the feasibility and safety of EUS-TA for biliary lesions, including the bile duct, gallbladder, and ampullary region.
A retrospective analysis was conducted on 68 patients with 71 biliary lesions who underwent EUS-TA at our institution between April 2017 and December 2024. Final diagnoses were established based on surgical specimens or clinical follow-up in non-surgical cases.

Results

Patient Background: The median age was 75 years (range: 50–90), and 46 patients (65%) were male. The lesions included 27 bile duct lesions (final diagnoses: 15 cholangiocarcinoma, 5 benign biliary stricture, 2 sclerosing cholangitis, 2 IgG4-related sclerosing cholangitis, 2 gallbladder cancer, 1 pancreatic cancer), 30 gallbladder lesions (19 gallbladder cancer, 3 xanthogranulomatous cholecystitis, 3 chronic cholecystitis, 2 post-acute cholecystitis change, 1 hilar cholangiocarcinoma, 1 gallbladder neuroendocrine carcinoma, 1 adenomyomatosis), and 14 ampullary lesions (9 ampullary carcinoma, 4 papillitis, 1 neuroendocrine tumor). Bile duct and ampullary lesions were cases where transpapillary diagnosis was inconclusive. Gallbladder lesions had distinct masses or wall thickening.
Outcomes: The median maximum lesion diameter was 17 mm (range: 3–67 mm). The median number of needle passes was 3 (range: 1–6). Needle sizes were 22G in 70 cases and 25G in 1 case. A fine-needle biopsy needle (FNB needle) was used in 61 cases (86%). The overall diagnostic yield (sensitivity/specificity/accuracy) for differentiating between benign and malignant lesions was 92.3%/100%/94.4%, respectively. In bile duct lesions, sensitivity sensitivity/specificity/accuracy were 80%/100%/85.2%, respectively. In gallbladder and ampullary lesions, diagnostic yield was 100%. Complications were observed in 3 cases (4.2%): one case each of obstructive jaundice, pancreatitis, and hyperamylasemia. One patient required transpapillary biliary drainage, while the others improved with conservative management. Surgery was performed in 21 patients (29.6%), with no cases of peritoneal dissemination observed.

Conclusion

EUS-TA demonstrates high diagnostic yield and safety for biliary lesions, offering a viable alternative when transpapillary approaches fail to differentiate benign from malignant pathology.

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.

Introduction

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective treatment for patients in whom transpapillary biliary drainage fails. However, EUS-HGS is associated with a high incidence of early procedure-relatedadverse events (PRAEs) due to bile leakage through a biliogastrointestinal fistula.

Aims & Methods

This multicenter study retrospectively evaluated the clinical outcomes of EUS-HGS. This study included 222 patients (120 men, 102 women; median age, 73 years) who underwent initial EUS-HGS between November 2014 and August 2024. Technical and clinical success rates, PRAEs, and stent dysfunction rates were analyzed. PRAEs were defined as adverse events occurring within 2 weeks according to the assessment of the American Society for Gastrointestinal Endoscopy.

Results

Benign and malignant tumors were observed in 18 (8.1%) and 204 (91.9%) patients, respectively. The median procedure time for EUS-HGS was 41 min (range, 11–173 minutes). Plastic and metal stents were deployed in 51.4% and 48.6% of the patients, respectively. Technical and clinical success rates and PRAEs were 97.8%, 85.1%, and 22.1%, respectively. The PRAEs were classified into mild (16.7%), moderate (4.1%), or severe (1.4%). Recurrent biliary obstruction (RBO) occurred in 51 (23.1%) patients. The median time to RBO in the metal stent group was significantly longer than that in the plastic stent group (313 vs. 162 days, P=0.02). Multivariate analysis identified the use of any dilation device (P=0.01; odds ratio [OR]: 3.55; 95% confidence interval [CI]: 1.35–9.36) and concomitant antegrade stenting (P=0.03; OR: 2.62; 95% CI: 1.12–6.12) as risk factors for PRAEs.

Conclusion

EUS-HGS is feasible; however, careful follow-up is required for patients undergoing fistula dilation and concomitant antegrade stenting.