Combined interventional radiology followed by endoscopic therapy as a single procedure for patients with failed initial endoscopic biliary access

Endoscopic ultrasound-rendezvous versus percutaneous-endoscopic rendezvous endoscopic retrograde cholangiopancreatography for bile duct access: Systematic review and meta-analysis

OBJECTIVES

Endoscopic ultrasound (EUS) or percutaneous-assisted antegrade guidewire insertion can be used to achieve biliary access when standard endoscopic retrograde cholangiopancreatography (ERCP) fails. We conducted a systematic review and meta-analysis to evaluate and compare the effectiveness and safety of EUS-assisted rendezvous (EUS-RV) and percutaneous rendezvous (PERC-RV) ERCP.

METHODS

We searched multiple databases from inception to September 2022 to identify studies reporting on EUS-RV and PERC-RV in failed ERCP. A random-effects model was used to summarize the pooled rates of technical success and adverse events with 95% confidence interval (CI).

RESULTS

In total, 524 patients (19 studies) and 591 patients (12 studies) were managed by EUS-RV and PERC-RV, respectively. The pooled technical successes were 88.7% (95% CI 84.6-92.8%, I2  = 70.5%) for EUS-RV and 94.1% (95% CI 91.1-97.1%, I2  = 59.2%) for PERC-RV (P = 0.088). The technical success rates of EUS-RV and PERC-RV were comparable in subgroups of benign diseases (89.2% vs. 95.8%, P = 0.068), malignant diseases (90.3% vs. 95.5%, P = 0.193), and normal anatomy (90.7% vs. 95.9%, P = 0.240). However, patients with surgically altered anatomy had poorer technical success after EUS-RV than after PERC-RV (58.7% vs. 93.1%, P = 0.036). The pooled rates of overall adverse events were 9.8% for EUS-RV and 13.4% for PERC-RV (P = 0.686).

CONCLUSIONS

Both EUS-RV and PERC-RV have exhibited high technical success rates. When standard ERCP fails, EUS-RV and PERC-RV are comparably effective rescue techniques if adequate expertise and facilities are feasible. However, in patients with surgically altered anatomy, PERC-RV might be the preferred choice over EUS-RV because of its higher technical success rate.

Outcomes of endoscopic retrograde cholangiopancreatography in patients with situs inversus viscerum

BACKGROUND/AIMS

Situs inversus viscerum (SIV) is a congenital condition defined by left-to-right transposition of all visceral organs. This anatomical variant has caused technical challenges in endoscopic retrograde cholangiopancreatography (ERCP). Data on ERCP in patients with SIV are limited to case reports of unknown clinical and technical success rates. This study aimed to evaluate the clinical and technical success rates of ERCP in patients with SIV.

METHODS

Data from patients with SIV who underwent ERCP were retrospectively reviewed. The data were collected by querying the nationwide Veterans Affairs Health System database for patients diagnosed with SIV who underwent ERCP. Patient demographics and procedural characteristics were collected.

RESULTS

Eight patients with SIV who underwent ERCP were included. Choledocholithiasis was the most common indication for ERCP (62.5%). The technical success rate was 63%. Subsequent ERCP with interventional radiology-assisted rendezvous has increased the technical success rate to 100%. Clinical success was achieved in 63% of cases. Among cases of subsequent rendezvous ERCP after conventional ERCP failure, clinical success was achieved in 100%.

CONCLUSION

The clinical and technical success rates of ERCP in patients with SIV were both 63%. In patients with SIV in whom ERCP fails, interventional radiology-assisted rendezvous ERCP can be considered.

Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) begins with successful biliary cannulation. However, it is not always be successful. The failure of the initial ERCP is attributed to two main aspects: the papilla/biliary orifice is endoscopically accessible, or it is inaccessible. When the papilla/biliary orifice is accessible, bile duct cannulation failure can occur even with advanced cannulation techniques, including double guidewire techniques, transpancreatic sphincterotomy, needle-knife precut papillotomy, or fistulotomy. There is currently no consensus on the next steps of treatment in this setting. Therefore, this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation. These options include interval ERCP, percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RV), and endoscopic ultrasound-assisted rendezvous procedures (EUS-RV). The overall success rate for interval ERCP was 76.3% (68%-79% between studies), and the overall adverse event rate was 7.5% (0-15.9% between studies). The overall success rate for PTE-RV was 88.7% (80.4%-100% between studies), and the overall adverse event rate was 13.2% (4.9%-19.2% between studies). For EUS-RV, the overall success rate was 82%-86.1%, and the overall adverse event rate was 13%-15.6%. Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise, facilities, or other specialists, it can be considered the first choice for salvage therapy. EUS-RV can also be considered if local experts are available. For patients in urgent need of biliary drainage, PTE-RV should be considered.

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

Safety and efficacy of percutaneous transhepatic-endoscopic rendezvous procedure in a single session

PURPOSE

To demonstrate the feasibility and safety of PTE-RV performed in a single session.

MATERIALS AND METHODS

This is a retrospective review of a prospective database on ERCP between January 2014 and December 2018. PTE-RV was performed in case of second ERCP failure. Technical success was defined as the establishment of an intestinal access to the biliary tract using a PTE-RV procedure allowing an immediate internal biliary drainage. Safety endpoints included intra-operative complications, morbidity and mortality occurring within 30 days after the procedure.

RESULTS

Eighty-four patients (44 M/40F) with a median age of 69 years (range 40-91 years) underwent combined PTE-RV. The PTE-RVs were successfully performed in the same session in 80 subjects, resulting in an overall technical success rate of 95.2%. Adverse events were observed in 19% (16/84) of cases. The mortality rate within 30 days after the procedure was 9.5%.

CONCLUSION

Percutaneous transhepatic-endoscopic rendezvous technique is feasible in a single session with acceptable level of risk. A randomized trial is required to compare EUBD and PTE-RV.

Solitary Duodenal Ulcer Causing Biliary Obstruction Requiring Rendezvous Procedure in a Pediatric Patient With Eosinophilic Gastroenteritis

Eosinophilic gastroenteritis (EGE) is an uncommon disease characterized by immune cell-mediated inflammation of the gastrointestinal (GI) tract resulting in vague abdominal symptoms, most commonly nausea, vomiting, diarrhea, and abdominal pain. We report the case of a 16-year-old male presenting with a six-week history of progressive pruritus, jaundice, fatigue, abdominal pain, acholic stools, and dark-colored urine. This patient was diagnosed via endoscopy with biliary obstruction caused by a large, solitary, duodenal ulcer secondary to EGE. This is a severe complication of EGE and to our knowledge, this is the first reported case of biliary obstruction caused by a duodenal ulcer in a pediatric patient with EGE. Additionally, we describe the first pediatric combined percutaneous-endoscopic rendezvous technique after failed therapeutic endoscopic retrograde cholangiography (ERCP) to relieve the biliary obstruction.

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in gastrointestinal and biliary diseases

In recent years, a wide range of gastrointestinal endoscopy techniques have been developed, such as endoscopic submucosal dissection (ESD) and endoscopic retrograde cholangiopancreatography (ERCP). Although ESD and ERCP have an important role in gastrointestinal and biliary diseases, each technique has its limitations. Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time. Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area. Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate. The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction, stenosis and bile duct injuries. For patients with simultaneous presence of stones in the gallbladder and the common bile duct, the laparo-endoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP. Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction. The most common used approach to deliver the magnets is by percutaneous-peroral tract. Laparoscopic-assisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.

Endoscopic palliation of biliary obstruction

Advanced pancreaticobiliary malignancy tends to be uncurable at presentation and causes significant morbidity for patients. Palliation for malignant biliary obstruction should be minimally invasive, cost-effective, and aim to improve quality of life of patients. Strategies of endoscopic palliation of malignant biliary obstruction can differ based on sites and degree of biliary obstruction with complex decisions of optimal stent type and placement that involve conscientious planning by a multidisciplinary team.

Percutaneous-transhepatic-endoscopic rendezvous procedures are effective and safe in patients with refractory bile duct obstruction

Background

Percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RVs) are rescue approaches used to facilitate biliary drainage.

Objective

The objective of this article is to evaluate the safety and the technical success of PTE-RVs in comparison with those of percutaneous transhepatic cholangiographies (PTCs).

Methods

Percutaneous procedures performed over a 10-year period were retrospectively analyzed in a single-center cohort. Examinations were performed because of a previous or expected failure of standard endoscopic methods including endoscopic retrograde cholangiography (ERC) or balloon-assisted ERC to achieve biliary access.

Results

In total, 553 percutaneous procedures including 163 PTE-RVs and 390 PTCs were performed. Overall, 71.3% of the patients suffered from malignant disease with pancreas-carcinoma (32.8%) and cholangio-carcinoma (19.0%) as the most frequent, while 28.7% of the patients suffered from benign disease. Many patients had a postoperative change in bowel anatomy (50.8%).PTC had a higher technical success rate (89.7%); however, the technical success rate of PTE-RVs was still high (80.4%; p < 0.003). Overall complications occurred in 23.5% of all procedures. Significantly fewer complications occurred after performing PTE-RVs than after PTCs (16.6% vs 26.4%; p = 0.037).

Conclusion

Beside a high technical efficacy of PTE-RVs, significantly fewer complications occur following PTE-RVs than following PTCs; thus, PTE-RV should be preferred over PTC alone in selected patients.

Usefulness of combined percutaneous-endoscopic rendezvous techniques after failed therapeutic endoscopic retrograde cholangiography in the era of endoscopic ultrasound guided rendezvous

The rendezvous approach is a salvage technique after failure of endoscopic retrograde cholangiography (ERC). In certain circumstances, percutaneous-endoscopic rendezvous (PE-RV) is preferred, and endoscopic ultrasound-guided rendezvous (EUS-RV) is difficult to perform. We aimed to evaluate PE-RV outcomes, describe the PE-RV techniques, and identify potential indications for PE-RV over EUS-RV.Retrospective analysis was conducted of a prospectively designed ERC database between January 2005 and December 2016 at a tertiary referral center including cases where PE-RV was used as a salvage procedure after ERC failure.During the study period, PE-RV was performed in 42 cases after failed therapeutic ERC; 15 had a surgically altered enteric anatomy. The technical success rate of PE-RV was 92.9% (39/42), with a therapeutic success rate of 88.1% (37/42). Potential indications for PE-RV over EUS-RV were identified in 23 cases, and either PE-RV or EUS-RV could have effectively been used in 19 cases. Endoscopic bile duct access was successfully achieved with PE-RV in 39 cases with accessible biliary orifice using one of PE-RV cannulation techniques (classic, n = 11; parallel, n = 19; and adjunctive maneuvers, n = 9).PE-RV uses a unique technology and has clinical indications that distinguish it from EUS-RV. Therefore, PE-RV can still be considered a useful salvage technique for the treatment of biliary obstruction after ERC failure.

Dilation of Strictures in Patients with Inflammatory Bowel Disease: Who, When and How

Stricture formation occurs in up to 40% of patients with inflammatory bowel disease (IBD). Patients are often symptomatic, resulting in significant morbidity, hospitalizations, and loss of productivity. Strictures can be managed endoscopically in addition to traditional surgical management (sphincteroplasty or resection of the affected bowel segments). About 3% to 5% patients with IBD develop primary sclerosing cholangitis (PSC), which results in stricture formation in the biliary tree, managed for the most part by endoscopic therapies. In this article, we discuss endoscopic management of strictures both in the alimentary tract and biliary tree in patients with IBD and/or PSC.

Pediatric Biliary Interventions

An interventional radiologist is frequently called to evaluate and treat biliary diseases in children; a tailored approach specific to this population is required. Imaging with an emphasis on minimizing ionizing radiation is used not only in the initial workup but also to guide interventions. The most common form of intervention generally consists of transhepatic biliary drainage to treat either biliary obstruction or bile leakage, a scenario frequently encountered after pediatric liver transplantation. Other pathologies referred for evaluation and management include biliary atresia and, rarely, symptomatic choledochal cysts. Biliary complications caused by an underlying malignancy are not a frequently encountered problem in the pediatric population. The initial evaluation, role of preprocedural imaging, and interventional management with an emphasis on technique are discussed regarding these common biliary pathologies in children.