EUS-guided Biliary Drainage with One-step Placement of Newly Designed Fully Covered Metal Stent for Malignant Biliary Obstruction: A Prospective Feasibility Study
Comments: EUS-guided biliary drainage (EUD) has been introduced for and alternative to percutaneous transhepatic biliary drainage (PTBD) in case of biliary obstruction when ERCP is unsuccessful.
However, results of EUS-guided biliary drainage with placement of plastic stent may have a frequent re-intervention rate due to the stent dysfunction.
Although self expandable metallic stent with a larger diameter might offer a long-lasting patency compared with that of plastic stent, to date, EUBD with one-step placement of a fully covered self expandable metal stent (FCSEMS) has not been evaluated.
Recently, fully covered metal stent with improvement of deployment and both flared ends for the prevention of migration has been developed.
This fully covered metal stent has an 8 F deployment system and olive tip (nitinol stent, 10mm in diameter, 4 to 6 cm in length). For prevention of distal or proximal migration, this stent has a both flared ends.
In this video, we introduce the intra and extraepatic approach of EUS-guided biliary drainage with one-step placement of newly designed fully covered metal stent.
Case 1
A 79 man year old man presented with obstructive jaundice.
On CT scan, extra and intrabile duct dilatation due to pancreas head cancer was noted.
For palliative biliary drainage, ERCP was performed. However, bile duct cannulation failed due to tumor infiltration of major papilla. Because patient refused a percutaneous biliary drainage, we performed EUS-guided biliary drainage.
For EUS-guided biliary drainage, the linear array echoendoscope was placed in the lesser curvature of high body and was oriented to visualize the left intrahepatic system.
Color Doppler was used to identify regional vasculature. Bile duct puncture was performed with 19-guage needle. TO confirm successful biliary access, contrast was instilled under fluoroscopy to demonstrate biliary opacification. A 0.035-inch guidewire was introduced through the EUS-needle and advanced in antegrade fashion.
And then, triple lumen needle knife with 7 F of shaft diameter was inserted over the guidewire to dilate the tract. For this, needle knife with pure current was gently over the guidewire to biliary system. And then, needle was withdrawn and needle knife pushed to dilate tract.
A fully covered metal stent with 8 F deployment system and olive tip was placed under echoendoscopic and fluoroscopic view. This stent with both flared ends was designed for prevention of distal or proximal migration. During stent placement, dark-colored bile was gushed out from fistula site.
Case 2
A 70 year old man with pancreatic cancer was admitted for obstructive jaundice.
On a CT scan, extrahepatic bile duct obstruction was noted.
For palliative biliary drainage, ERCP was performed. However, bile duct cannulation failed due to ulcerative tumor infiltration of major papilla. Because patient refused a percutaneous biliary drainage, we performed EUS-guided biliary drainage.
The extrahepatic approach was performed with the echoendoscope in the distal antrum or bulb of duodenum, permitting imaging of the choledochus. Color Doppler was used to identify regional vasculature. CBD showed a marked dilatation with echogenic materials. Bile duct puncture was performed with 19-guage needle. To confirm successful biliary access, contrast was instilled under fluoroscopy to demonstrate biliary opacification. A 0.035-inch guidewire was introduced through the EUS-needle and advanced in retrograde fashion to hilum.
Triple lumen needle knife (Microtome) with 7 F of Shaft diameter was inserted over the guidewire to dilate the tract. For this, needle knife was pure current was gently over the guidewire to biliary system. And then, needle was withdrawn and needle knife pushed to dilate tract. Fully covered metal stent was placed under echoendoscopic and fluoroscopic view.
Follow-up plain simple abdominal film showed a placement of full covered metal stent via choledchodudenostomy.
Results
Total 12 patients (6 women and 6 men) were enrolled in this study (gallbladder cancer n=2, pancreatic cancer n=4, hepatoma n=1, advanced gastric cancer n=2, bladder cancer n=1, colon cancer n=1, and klatskin tumor n=1).
The median age was 66 years (39-79 ears). Technical success and functional success was 100% (12/12). Median procedure time was 25 minutes (range 18-38 minutes).
Because duodenal obstruction and compromised duodenal blub due to involvement of tumor, seven patients underwent intrahepatic approach (6 in transgastric, and 1 in transesophageal).
Remaining five patients underwent extraheptic approach (four in transduodenal, and 1 in transantral) due to the insufficient intraheatic bile duct dilatation.
In intrahepatic approach, two patients showed a self-limited pneumoperitoenum. This complication was conservatively managed. In extrahepatic approach, there was no procedural complication such as bile peritonitis or perforation.
During follow-up periods, there was no re-intervention regarding stent migration or stent malfunction due to gastric food impaction.
In conclusion, EUD with one-step placement of fully covered metal stent may be feasible, safe, and effective for an alternative to percutaneous transhepatic biliary drainage (PTBD) in case of malignant biliary obstruction when ERCP is unsuccessful.
| Contributed by: |
Do Hyun Park, M.D. PhD Physician Soon Chun Hyang University |
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Citation: Park PhD, DH (Jun 01 2009). EUS-guided Biliary Drainage with One-step Placement of Newly Designed Fully Covered Metal Stent for Malignant Biliary Obstruction: A Prospective Feasibility Study. The DAVE Project. Retrieved Feb, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=859 Times viewed since Feb 2006: 2198 |
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