Interventional EUS: difficult pancreaticobiliary access

EUS-guided hepaticogastrostomy

EUS-guided biliary drainage (BD) is an option to treat obstructive jaundice when ERCP drainage fails. These procedures represent alternatives to surgery and percutaneous transhepatic BD and have been made possible through the continuous development and improvement of EUS scopes and accessories. The development of linear sectorial array EUS scopes in early 1990 brought a new approach to the diagnostic and therapeutic dimensions of echoendoscopy capabilities, opening the possibility to perform puncture over a direct ultrasonographic view. Despite the high success rate and low morbidity of BD obtained by ERCP, difficulty can arise with an ingrown stent tumor, tumor gut compression, periampullary diverticula, and anatomic variation. The EUS-guided technique requires puncture and contrast of the left biliary tree. When performed from the gastric wall, access is obtained through hepatic segment III. Diathermic dilation of the puncturing tract is performed using a 6F cystotome and a plastic or metallic stent. The technical success of hepaticogastrostomy is near 98%, and complications are present in 15%–20% of cases. The most common complications include pneumoperitoneum, bilioperitoneum, infection, and stent dysfunction. To prevent bile leakage, we used a special partially covered stent (70% covered and 30% uncovered). Over the last 15 years, the technique has typically been performed in reference centers, by groups experienced with ERCP. This seems to be a general guideline for safer execution of the procedure.

Dual drainage using a percutaneous pancreatic duct technique contributed to resolution of severe acute pancreatitis

A 66-year-old man was admitted for severe acute alcoholic pancreatitis with infected pancreatic necrosis (IPN). Abdominal computed tomography revealed an inflamed pancreatic head, a dilated main pancreatic duct (MPD), and a large cavity with heterogeneous fluid containing gas adjacent to the pancreatic head, and extending to the pelvis. The cavity was drained percutaneously near the pancreatic head on admission; another tube was inserted into the pelvic cavity on hospital day 3. The drained fluid contained pus with high amylase concentration. Nasopancreatic drainage tube placement was unsuccessfully attempted on hospital day 9. On hospital day 23, percutaneous puncture of the MPD and placement of a pancreatic duct drainage tube was performed. Pancreatography revealed major extravasation from the pancreatic head. The IPN cavity receded; the percutaneous IPN drainage tube was removed on hospital day 58. On hospital day 83, the pancreatic drainage was changed to a transpapillary pancreatic stent, and the patient was discharged. Measuring the amylase concentration of peripancreatic fluid collections can aid in the diagnosis of pancreatic duct disruption; moreover, dual percutaneous necrotic cavity drainage plus pancreatic duct drainage may be essential for treating IPN. If transpapillary drainage tube placement is difficult, percutaneous pancreatic duct drainage may be feasible.

Endoscopic ultrasonography guided drainage: summary of consortium meeting, May 21, 2012, San Diego, California

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary and pancreatic drainage. While ERCP is successful in about 95% of cases, a small subset of cases are unsuccessful due to altered anatomy, peri-ampullary pathology, or malignant obstruction. Endoscopic ultrasound-guided drainage is a promising technique for biliary, pancreatic and recently gallbladder decompression, which provides multiple advantages over percutaneous or surgical biliary drainage. Multiple retrospective and some prospective studies have shown endoscopic ultrasound-guided drainage to be safe and effective. Based on the currently reported literature, regardless of the approach, the cumulative success rate is 84%-93% with an overall complication rate of 16%-35%. endoscopic ultrasound-guided drainage seems a viable therapeutic modality for failed conventional drainage when performed by highly skilled advanced endoscopists at tertiary centers with expertise in both echo-endoscopy and therapeutic endoscopy.

Endoscopic Ultrasound-guided Bilio-pancreatic Drainage

The echoendoscopic biliary drainage is an option to treat obstructive jaundices when endoscopic retrograde cholangiopancreatography (ERCP) drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear sectorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimension on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonografic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampullary diverticula and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Diathermic dilatation of the puncturing tract is required using a 6-Fr cystostome and a plastic or metal stent is introducted. The techincal success of hepaticogastrostomy is near 98%, and complications are present in 20%: pneumoperitoneum, choleperitoneum, infection and stent disfunction. To prevent bile leakage, we have used the 2-stent techniques. The first stent introduced was a long uncovered metal stent (8 or 10 cm) and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92%, and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 14%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution. The ideal approach for pancreatic pseudocyst (PPC) puncture combines endos-copy with real time endosonography using an interventional echoendoscope. Several authors have described the use of endoscopic ultrasound (EUS) longitudinal scanners for guidance of transmural puncture and drainage procedures. The same technique could be used to access a dilated pancreatic duct in cases in which the duct cannot be drained by conventional ERCP because of complete obstruction.

Endocoil placement after endoscopic ultrasound-guided biliary drainage may prevent a bile leak

AIM: To further reduce the risk of bleeding or bile leakage.

METHODS: We performed endoscopic ultrasound guided biliary drainage in 6 patients in whom endoscopic retrograde cholangiopancreatography (ERCP) had failed. Biliary access of a dilated segment 2 or 3 duct was achieved from the stomach using a 19G needle. After radiologically confirming access a guide wire was placed, a transhepatic tract created using a 6 Fr cystotome followed by balloon dilation of the stricture and antegrade metallic stent placement across the malignant obstruction. This was followed by placement of an endocoil in the transhepatic tract.

RESULTS: Dilated segmental ducts were observed in all patients with the linear endoscopic ultrasound scope from the proximal stomach. Transgastric biliary access was obtained using a 19G needle in all patients. Biliary drainage was achieved in all patients. Placement of an endocoil was possible in 5/6 patients. All patients responded to biliary drainage and no complications occurred.

CONCLUSION: We show that placing endocoils at the time of endoscopic ultrasound guided biliary stenting is feasible and may reduce the risk of bleeding or bile leakage.

EUS-Guided Biliary Drainage

The echoendoscopic biliary drainage is an option to treat obstructive jaundices when ERCP drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear setorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimenion on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonographic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampulary diverticula, and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Dilatation is required before stent introduction, and a plastic or metallic stent is introduced. This phrase should be replaced by: diathermic dilatation of the puncturing tract is required using a 6F cystostome. The technical success of hepaticogastrostomy is near 98%, and complications are present in 36%: pneumoperitoneum, choleperitoneum, infection, and stent disfunction. To prevent bile leakage, we have used the 2 stent techniques, the first stent introduced was a long uncovered metallic stent (8 or 10 cm), and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92% and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 19%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution.

Endoscopic ultrasound in pancreatic disease--its influence on surgical decision-making. An update 2008

Endoscopic ultrasonography (EUS) was introduced about 25 years ago with the primary aim of better visualization of the pancreas as compared to transabdominal ultrasonography. This review discusses the current evidence in 2008 concerning the role of EUS in the clinical management of patients, with a special emphasis on its impact on surgical therapy. According to the literature, good indications are detection of common bile duct stones (e.g. in acute pancreatitis), the detection of small exo- and endocrine pancreatic tumors, the performance of fine-needle aspiration in pancreatic masses depending on therapeutic consequences. In other areas such as diagnosis of chronic pancreatitis and cystic pancreatic lesions, the contribution of EUS seems limited. Pancreatic cancer staging is discussed controversially due to conflicting evidence and certainly has lost grounds due to improvements in CT technology. Therapeutic EUS is, however, more widely accepted and may replace other techniques, e.g. in pancreatic cyst drainage and celiac plexus neurolysis; further techniques of interest are being developed.