Introduction: An 80 yo male was referred for jaundice due to cancer of the pancreatic head resulting in obstruction of the distal common bile duct (CBD). An attempt at ERCP had already been undertaken but failed due to periampullary tumour invasion and ulceration. Informed consent for attempted EUS guided access to the biliary tree was given after discussing alternative therapies (ie-percutaneous transhepatic cholangiography)
Video: A therapeutic linear array echoendoscope was passed and the ampulla inspected. A normal appearing ampulla was identified with proximal ulceration of the duodenum consistent with local invasion. A pre-cut access sphincterotomy had not been performed given the underlying tumour. Endosonographic exam was undertaken in the bulb where a dilated CBD was identified, this can be seen here measuring 13mm. The CBD tapers abruptly as it enters the tumour in the pancreatic head. Color flow Doppler does not show any vessels that prohibit puncture of the CBD. A 19g FNA needle is chosen to ultimately allow passage of a 0.035 guidewire The needle can be seen entering the CBD here. Contrast is injected into the CBD under fluoroscopy to confirm biliary location. A 0.035 guidewire is passed into the CBD. The guidewire passed in an antegrade fashion and can be seen looping into the duodenum. Had the guidewire travelled towards the intra-hepatic ducts we were prepared to place a fully covered transduodenal SEM stent. The echoendoscope is then exchanged out while maintaining guidewire position. A side viewing endoscope is then passed into the duodenal bulb. The guidewire can be seen here entering the CBD. Note the dark bile that is flowing from the choledochoduodenostomy site. The papilla is seen here with the guidewire protruding through. Cannulation of the CBD alongside the wire is performed. Once deep cannulation is obtained, further contrast is injected- Note the lack of contrast entering the distal CBD consistent with a high-grade distal biliary stricture. Biliary dilation is performed using a graduated biliary dilation catheter. After this is complete, a 10x60mm self-expanding metal stent is placed across the biliary stricture and deployed successfully. Note, the tight waist of the stent corresponding to the strictured region.
Experience with EUS guided access to the biliary system is increasing. This technique has been used to gain biliary access in both malignant and non-malignant conditions.
Shah et al reviewed patients that had a failed ERCP or a papilla that was inaccessible due to surgically altered anatomy. 95 cases of EUS guided biliary or pancreatic access were identified. EUS guided rendezvous was successful in 75% of patients. Ten complications were reported with one perforation and one bile leak.
Park et al performed EUS guided intra and extra-hepatic biliary access in 57 patients in whom ERCP failed. Technical success of 96.5% was reported. 11 patients developed complications; 7 of these were self-limited pneumoperitoneum.
In multivariate analysis, the use of a needle knife was associated with an adverse event (odds ratio of 12).
A small prospective trial randomized 21 patients with unresectable distal biliary malignant obstructions to EUS guided biliary drainage vs. PTC. There was no statistically significant difference in technical success, complication rate, or survival in the two groups. EUS guided biliary drainage was found to be a more cost effective in those with limited left expectancy while PTC more cost effective in those with longer life expectancy
EUS guided biliary drainage allows for intervention to be performed in a single session.
Early data suggest EUS guided biliary drainage to be safe with no deaths reported and few perforations.
Larger randomized trials comparing EUS guided biliary drainage with PTC are needed to confirm this as a first line option in failed ERCP.
No financial disclosures to be made by the authors.
Shah JN, Marson F, Weilert F, et al. Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla. Gastrointest Endosc. 2011 Oct 19.
Park DH, Jang JW, Lee SS, et al. EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc. 2011 Sep 29.
Artifon EL, Aparicio DP, Gupta K, et al. A Prospective Trial of EUS-Guided Choledochoduodenostomy Versus Percutaneous Transhepatic Biliary Drainage in Patients With Unresectable Distal Biliary Malignant Obstruction. Oral Presentation DDW Sunday May 8th 2011, Chicago
Serag Dredar, MD, Yale University
Harry Aslanian, M.D., Yale University