Urgent endoscopic ultrasound-guided choledochoduodenostomy for acute obstructive suppurative cholangitis-induced sepsis

Acute obstructive suppurative cholangitis(AOSC) due to biliary lithiasis is a life-threatening condition that requires urgent biliary decompression. Although endoscopic retrograde cholangiopancreatography(ERCP) with stent placement is the current gold standard for biliary decompression, it can sometimes be difficult because of failed biliary cannulation. In this retrospective case series, we describe three cases of successful biliary drainage with recovery from septic shock after urgent endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) was performed for AOSC due to biliary lithiasis. In all three cases, technical success in inserting the stents was achieved and the patients completely recovered from AOSC with sepsis in a few days after EUS-CDS. There were no procedure-related complications. When initial ERCP fails, EUS-CDS can be an effective life-saving endoscopic biliary decompression procedure that shortens the procedure time and prevents post-ERCP pancreatitis, particularly in patients with AOSC-induced sepsis.

Long-term results of choledochoduodenostomy in benign biliary obstruction

AIM:To determine the long-term results of choledochodudenostomy in patients with benign billiary obstruction.METHODS:This prospective study was conducted at Sheri Kashmir Institute of Medical Sciences Srinagar Kashmir,India over a period of 10 years from January 1997 to December 2007.The total number of patients who underwent choledochoduodenostomy during this period was 270.On the basis of etiology of biliary tract obstruction,patients were divided into a calculus group,an oriental cholangiohepatitis group,a benign biliary stricture group and others.Patients were followed for a variable period of 13 mo to 15 years.RESULTS:Choledochoduodenostomy(CDD) with duodenotomy was performend in four patients.CDD with removal of T-tube,CDD with left hepatic lobectomy and CDD with removal of intra biliary ruptured hydatid was performed in three patients each.In the remaining patients only CDD was performed.Immediate post operative complications were seen in 63(23%) patients,while long-term complications were seen in 28(11%) patients,which were statistically significant.Three patients died during hospitalization while four patients died in the late post-operative period.CONCLUSION:Our conclusion is that CDD is safe and produces good long term results when a permanent biliary drainage procedure is required.

Laparoscopic Choledochoduodenostomy for Biliary Alleviation

Choledochoduodenostomy (CDD) was very useful alternatives for treatment for patients with common bile duct (CBD) stones, especially recurrent stones, giant stones with choledochal dilatation, and difficult or failed cases by endoscopic treatment. Furthermore, CDD was also applied to biliary bypass by malignant obstruction. In these days, minimal invasive laparoscopic approach is adapted in these disorders. We have conducted to perform a laparoscopic CDD for biliary alleviation for patients with endoscopic management of difficult CBD stone with choledochal dilatation. A side-to-side CDD was created intra-corporeally using water-tight running absorbable suture by handmade 4-0 monofilament with double side needles, starting from the right side of choledochus, and continued along posterior wall until the left side of the choledochus followed by anterior-wall anastomosis as the same manner. Five patients were treated successfully by this laparoscopic procedure and remained well without bile leakage and reflux cholangitis for the short-term follow-up. The median operative time and intracorporeally anastomosis time were 182 (167 - 209) min and 33 (30 - 38) min, respectively. Median blood loss was 32 (little-90) ml, median hospital stay was 7 (5 - 14) days, and median follow-up time was 18 months. Although this series was relatively small, this laparoscopic technique is feasible and safe for biliary alleviation, especially for endoscopic management of difficult or failed CBD stones, and would also potentially adapt to biliary bypass by malignant obstruction.

Role of endoscopic-ultrasound-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction

In this editorial,we discuss the article by Peng et al in the recent issue of the World Journal of Gastrointestinal Surgery,focusing on the evolving role of endoscopicultrasound-guided biliary drainage(EUS-BD)with electrocautery lumen apposing metal stent(LAMS)for distal malignant biliary obstruction.Therapeutic endoscopy has rapidly advanced in decompression techniques,with growing evidence of its safety and efficacy surpassing percutaneous and surgical approaches.While endoscopic retrograde cholangiopancreatography(ERCP)has been the gold standard for biliary decompression,its failure rate approaches 10.0%,prompting the exploration of alternatives like EUS-BD.This random-effects meta-analysis demonstrated high technical and clinical success of over 90.0% and an adverse event rate of 17.5%,mainly in the form of stent dysfunction.Outcomes based on stent size were not reported but the majority used 6 mm and 8 mm stents.As the body of literature continues to demonstrate the effectiveness of this technique,the challenges of stent dysfunction need to be addressed in future studies.One strategy that has shown promise is placement of double-pigtail stents,only 18% received the prophylactic intervention in this study.We expect this to improve with time as the technique continues to be refined and standardized.The results above establish EUS-BD with LAMS as a reliable alternative after failed ERCP and considering EUS to ERCP upfront in the same session is an effective strategy.Given the promising results,studies must explore the role of EUS-BD as first-line therapy for biliary decompression.

Long-term outcomes of choledochoduodenostomy for hepatolithiasis

Background Oddi sphincter plays an important role in preventing reflux cholangitis. There exists the controversy on application of choledochoduodenostomy in hepatolithiasis management. The present study aimed at evaluating long-term outcomes of choledochoduodenostomy for the treatment of hepatolithiasis. Methods Forty-six consecutive cases of hepatolithiasis who underwent choledochoduodenostomy were analyzed retrospectively. The pre- and postoperative rates of recurrent cholangitis and acute cholangitis severe type were compared. Paired chi-square test was applied. Results The mean follow-up time was 17.3 years ranging from 1.6 to 40 years with a follow-up rate of 97.8% （45/46）. High rates of remnant stones （39.1%, 18/46）, recurrent stones （31.1%, 14/45）, uncorrected strictures （85%, 17/20）, and mortality （24.4%, 11/45） were observed in this group. Regurgitation of food debris and duodenal content into the biliary tract through the anastomosis was observed. The rate of recurrent cholangitis was equal to the preoperative period （93.3%, 42/45）. The rate of acute cholangitis severe type after choledochoduodenostomy （46.7%, 21/45） increased significantly （P 〈0.01） when compared to the preoperative period （20.0%, 9/45）. Conclusions Choledochoduodenostomy did not entirely achieve the goal of clearance of stones, correction of strictures, and removing of hepatobiliary lesions by itself. Chofedochoduodenostomy without cholangioplasty resulted in an increase of severe reflux cholangitis due to the loss of the anti-reflux function of the sphincter of Oddi. Therefore, choledochoduodenostomy is not an ideal approach to reduce cholangitis in hepatolithiasis and is not the best choice in the management of hepatolithiasis.

A novel technique for endoscopic ultrasound-guided biliary drainage

AIM: To describe a successful endoscopic ultrasound (EUS)-guided biliary drainage technique with high success and low complication rates. METHODS: The recorded data of consecutive patients who presented to Siriraj Gastrointestinal Endoscopy Center, Siriraj Hospital in Bangkok, Thailand for treatment of malignant obstructive jaundice but failed endoscopic retrograde cholangiopancreatography and underwent subsequent EUS-guided biliary drainage were retrospectively reviewed. The patients' baseline characteristics, clinical manifestations, procedure details, and post-procedure follow-up data were recorded and analyzed. Clinical outcomes were assessed by physical exam and standard laboratory tests. Technical success of the procedure was defined as completion of the stent insertion. Clinical success was defined as improvement of the patient's overall clinical manifestations, in terms of general well-being evidenced by physical examination, restoration of normal appetite, and adequate biliary drainage. Overall median survival time was calculated as the time from the procedure until the time of death, and survival analysis was performed by the Kaplan-Meier method. The Student's t -test and the χ 2 test were used to assess the significance of inter-group differences. RESULTS: A total of 21 cases were enrolled, a single endoscopist performed all the procedures. The mean age was 62.8 years (range: 46-84 years). The sex distribution was almost equal, including 11 women and 10 men. Patients with failed papillary cannulation (33.3%), duodenal obstruction (42.9%), failed selective cannulation (19.0%), and surgical altered anatomy (4.8%) were considered candidates for EUS-guided biliary drainage. Six patients underwent EUS-guided choledochoduodenostomy and 15 underwent EUS-guided hepaticogastrostomy. The technique using non-cauterization and no balloon dilation was performed for all cases, employing the in-house manufactured tapered tip Teflon catheter to achieve the dilation. The technical success and clinical success rates of this technique were 95.2% and 90.5%, respectively. Complications included bile leakage and pneumoperitoneum, occurred at a rate of 9.5%. None of the patients died from the procedure. One patient presented with a biloma, a major complication that was successfully treated by another endoscopic procedure. CONCLUSION: We present a highly effective EUS-guided biliary drainage technique that does not require cauterization or balloon dilation.

Endoscopic ultrasound-guided biliary drainage as an alternative to percutaneous drainage and surgical bypass

Endoscopic retrograde cholangiopancreatography had been a treatment modality of choice for both benign and malignant biliary tract obstruction for more than half century, with a very high clinical success rate and low complications. But in certain circumstances, such as advanced and locally advanced pancreatobiliary malignancies(pancreatic cancer, cholangiocarcinoma, ampullary tumor) and tight benign strictures, endoscopic retrograde cholangiopancreatography(ERCP) fails. Up to this point, the only alternative interventions for these conditions were percutaneous transhepatic biliary drainage or surgery. Endoscopic ultrasound guided interventions was introduced for a couple decades with the better visualization and achievement of the pancreatobiliary tract. And it's still in the process of ongoing development. The inventions of new techniques and accessories lead to more feasibility of high-ended procedures. Endoscopic ultrasound guided biliary drainage was a novel treatment modality for the patient who failed ERCP with the less invasive technique comparing to surgical bypass. The technical and clinical success was high with acceptable complications. Regarded the ability to drain the biliary tract internally without an exploratory laparotomy, this treatment modality became a very interesting procedures for many endosonographers, worldwide, in a short period. We have reviewed the literature and suggest that endoscopic ultrasoundguided biliary drainage is also an option, and one with a high probability of success, for biliary drainage in the patients who failed conventional endoscopic drainage.

Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy

AIM: To evaluate the efficacy of endoscopic ultrasound guided biliary drainage(EUS-BD) in patients with surgically altered anatomies.METHODS: We performed a search of the MEDLINE database for studies published between 2001 to July2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms "EUS drainage" and "altered anatomy". All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only fulltext English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth Ⅰ; group 2, Billroth Ⅱ; group 4, Rouxen-Y with gastric bypass; and group 3, all other types. RESULTS: Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion. CONCLUSION: EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrogradecholangiography in centers with expertise in EUS-BD procedures in a research setting.

endoscopic ultrasonography-guided biliary drainage:Who,when,which,and how?

Both endoscopic ultrasonography(EUS)-guided choledochoduodenostomy( EUS- CDS) and EUS-guided hepaticogastrostomy(EUS-HGS) are relatively well established as alternatives to percutaneous transhepatic biliary drainage(PTBD). Both EUSCDS and EUS-HGS have high technical and clinical success rates(more than 90%) in high-volume centers. Complications for both procedures remain high at 10%-30%. Procedures performed by endoscopists who have done fewer than 20 cases sometimes result in severe or fatal complications. When learning EUSguided biliary drainage(EUS-BD), we recommend a mentor's supervision during at least the first 20 cases. For inoperable malignant lower biliary obstruction, a skillful endoscopist should perform EUS-BD before EUS-guided rendezvous technique(EUS-RV) and PTBD. We should be select EUS-BD for patients having altered anatomy from malignant tumors before balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography, EUS-RV, and PTBD. If both EUS-CDS and EUS-HGS are available, we should select EUS-CDS, according to published data. EUSBD will potentially become a first-line biliary drainage procedure in the near future.

Comprehensive review on EUS-guided biliary drainage

Feasibility of endoscopic retrograde cholangiopancreatography(ERCP) for biliary drainage is not always applicable due to anatomical alterations or to inability to access the papilla. Percutaneous transhepatic biliary drainage has always been considered the only alternative for this indication. However,endoscopic ultrasonography-guided biliary drainage represents a valid option to replace percutaneous transhepatic biliary drainage when ERCP fails. According to the access site to the biliary tree,two kinds of approaches may be described: the intrahepatic and the extrahepatic. Endoscopic ultrasonography-guided rendezvous transpapillary drainage is performed where the second portion of the duodenum is easily reached but conventional ERCP fails. The recent introduction of self-expandable metal stents and lumen-apposing metal stents has improved this field. However,the role of the latter is still controversial. Echoendoscopic transmural biliary drainage can be challenging with potential severe adverse events. Therefore,trained endoscopists,in both ERCP and endoscopic ultrasonography are needed with surgical and radiological backup.

Endoscopic ultrasound-guided biliary drainage: A change in paradigm?

Endoscopic ultrasound-guided biliary drainage(EUS-BD) has been developed as an alternative means of biliary drainage for malignant biliary obstruction(MBO).Compared to percutaneous transhepatic biliary drainage,EUS-BD offers effective internal drainage in a single session in the event of failed endoscopic retrograde cholangiopancreatography and has fewer adverse events(AE). In choosing which technique to use for EUS-BD,a combination of factors appears to be important in decision-making; technical expertise,the risk of AE,and anatomy. With the advent of novel all-in-one EUS-BD specific devices enabling simpler and safer techniques,as well as the growing experience and training of endosonographers,EUS-BD may potentially become a first-line technique in biliary drainage for MBO.

Endoscopic ultrasound-guided drainage of the biliary system:Techniques,indications and future perspectives

Over the last decade, endoscopic ultrasound-guided biliary drainage(EUS-BD)has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde cholangiopancreaticography(ERCP). The available evidence suggests that, in experienced hands, EUS-BD might even replace ERCP as the first-line procedure in specific situations such as malignant distal bile duct obstruction. The aim of this review is to summarize the available data on EUS-BD and propose an evidence-based algorithm clarifies the role of the different EUS-BD techniques in the management of benign and malignant biliary obstructive disease.

Endoscopic ultrasound-guided biliary drainage-current status and future perspectives

Endoscopic retrograde cholangiopancreatography(ERCP)with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction.ERCP could fail in cases of duodenal obstruction,duodenal diverticulum,ampullary neoplastic infiltration or surgically altered anatomy.In these cases percutaneous biliary drainage(PTBD)is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices.A large amount of data is already collected that proves its efficacy,safety and ability to replace PTBD in cases of ERCP failure.It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future.Several EUS-BD techniques are developed EUS-guided transmural stenting,antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy.EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure.The lack of training,absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure,which is related to life-threatening adverse events.Developing training models,dedicated devices and guidelines hopefully will make EUS-BD easier,safer and well accepted in the future.This paper focuses on the technical aspects of the different EUS-BD procedures,available literature data,advantages,negative aspects and the future perspectives of these modalities.

Endoscopic ultrasound-guided biliary drainage:Are we there yet?

Endoscopic retrograde cholangiopancreatography(ERCP)is the mainstay procedure of choice for management of obstructive biliary disease.While ERCP is widely performed with high success rates,the procedure is not feasible in every patient such as cases of non-accessible papilla.In the setting of unsuccessful ERCP,endoscopic ultrasound-guided biliary drainage(EUS-BD)has become a promising alternative to surgical bypass and percutaneous biliary drainage(PTBD).A variety of different forms of EUS-BD have been described,allowing for both intrahepatic and extrahepatic approaches.Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage,with fewer adverse events when compared to PTBD.Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure.The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists.The aim of our review is to highlight the different EUSguided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.

Feasibility of therapeutic endoscopic ultrasound in the bridge-to-surgery scenario:The example of pancreatic adenocarcinoma

Upfront resection is becoming a rarer indication for pancreatic ductal adenocarcinoma,as biologic behavior and natural history of the disease has boosted indications for neoadjuvant treatments.Jaundice,gastric outlet obstruction and acute cholecystitis can frequently complicate this window of opportunity,resulting in potentially deleterious chemotherapy discontinuation,whose resumption relies on effective,prompt and long-lasting management of these complications.Although therapeutic endoscopic ultrasound(t-EUS)can potentially offer some advantages over comparators,its use in potentially resectable patients is primal and has unfairly been restricted for fear of potential technical difficulties during subsequent surgery.This is a narrative review of available evidence regarding EUS-guided choledochoduodenostomy,gastrojejunostomy and gallbladder drainage in the bridge-to-surgery scenario.Proof-ofconcept evidence suggests no influence of t-EUS procedures on outcomes of eventual subsequent surgery.Moreover,the very high efficacy-invasiveness ratio over comparators in managing pancreatic cancer-related symptoms or complications can provide a powerful weapon against chemotherapy discontinuation,potentially resulting in higher subsequent resectability.Available evidence is discussed in this short paper,together with technical notes that might be useful for endoscopists and surgeons operating in this scenario.No published evidence supports restricting t-EUS in potential surgical candidates,especially in the setting of pancreatic cancer patients undergoing neoadjuvant chemotherapy.Bridge-to-surgery tEUS deserves further prospective evaluation.