Radiologic Assessment for Endoscopic US-guided Biliary Drainage

EUS-guided hepaticogastrostomy: practical tips and tricks

Background and Aims

EUS-guided hepaticogastrostomy (EUS-HGS) has gained traction as a reliable and safe method for definitive biliary drainage in patients who cannot undergo traditional transampullary procedures. Many of the newly developed single-stage devices are not yet approved for clinical use in Western practice.

Methods

We highlight key clinical and technical aspects of EUS-HGS using devices that are currently available in Western countries. The article is a comprehensive step-by-step technical review of EUS-HGS, and the video demonstrates high-level tips to overcome commonly encountered procedural challenges.

Results

Patients with biliary obstruction underwent EUS-HGS at our center. The technical difficulties that were encountered are highlighted in the article and the accompanying video. The article and video provide a detailed review of (1) preprocedural considerations, (2) puncture site selection, (3) biliary puncture, (4) contrast injection, (5) guidewire manipulation, (6) tract dilation, and (7) stent placement.

Conclusion

An understanding and implementation of the technical nuances highlighted in this article should help Western endoscopists navigate the complexities of EUS-HGS and ensure optimal outcomes.

The gallbladder: what's new in 2022?

This review focuses mainly on the imaging diagnosis, treatment, and complications of acute cholecystitis which is the most common benign disease of the gallbladder. The American College of Radiology appropriateness criteria for the imaging evaluation of patients with right upper quadrant pain and the Tokyo Guidelines for evaluating patients with acute cholecystitis and acute cholangitis are presented. The recent articles for using US, CT, MR, and HIDA in the evaluation of patients with suspected acute cholecystitis are reviewed in detail. The clinical management and postoperative complications are described. Because gallbladder polyps and adenomyomatosis can mimic gallbladder malignancies and acute cholecystitis, their imaging findings and management are presented. Finally, due the recent literature reporting better results with CT than US in the diagnosis of acute cholecystitis, a suggested approach for imaging patients with right upper quadrant pain and possible acute cholecystitis is presented in an addendum.

Choledochoduodenostomy Versus Hepaticogastrostomy in Endoscopic Ultrasound-guided Drainage for Malignant Biliary Obstruction: A Meta-analysis and Systematic Review

OBJECTIVES

This study aimed to estimate the safety and efficacy of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for malignant biliary obstruction.

METHODS

We conducted a literature search using PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Studies that compared EUS-CDS and EUS-HGS were included in this study.

RESULTS

Thirteen studies were eligible for inclusion. The technical [odds ratio (OR): 0.95; 95% confidence interval (CI): 0.51-1.74) and clinical (OR: 1.13; 95%CI: 0.66-1.94) success rates of EUS-CDS were comparable to those of EUS-HGS. However, EUS-CDS had less reintervention (OR: 0.31; 95%CI: 0.16-0.63) and stent obstruction (OR: 0.48; 95%CI: 0.21-0.94) than EUS-HGS. Both groups had similar adverse events (OR: 1.00; 95%CI: 0.70-1.43) and overall survival (hazard ratio: 1.07; 95%CI: 0.58-1.97).

CONCLUSIONS

EUS-CDS and EUS-HGS have comparable technical and clinical success rates, adverse events, and overall survival. However, EUS-CDS has less reintervention and stent obstruction.

Conversion of percutaneous transhepatic biliary drainage to endoscopic ultrasound-guided biliary drainage

INTRODUCTION

Percutaneous transhepatic biliary drainage (PTBD) is a useful alternative treatment for malignant biliary obstruction (MBO) when patients have difficulty with endoscopic transpapillary drainage. We examined the feasibility of conversion of PTBD to endoscopic ultrasound-guided biliary drainage (EUS-BD) in patients with MBO unsuited for endoscopic transpapillary biliary drainage.

METHODS

This retrospective study included patients who underwent conversion of PTBD to EUS-BD between March 2017 and December 2019. Eligible patients had unresectable MBO, required palliative biliary drainage, and were not suited for endoscopic transpapillary drainage. Initial PTBD had been performed for acute cholangitis or obstructive jaundice in all patients. EUS-BD was performed following improvements in cholangitis. Sixteen patients underwent conversion of PTBD to EUS-BD. We evaluated technical success, procedure time, clinical success (defined as subsequent external catheter removal), adverse events (AEs), time to recurrent biliary obstruction (TRBO), and re-intervention rates.

RESULTS

Technical success was achieved in all patients (100%). The median procedure time was 45.0 minutes (interquartile range [IQR] 30.0-50.0 minutes). Clinical success was achieved in all patients (100%). There were mild early AEs in two patients (12.5%) (acute cholangitis: 1, bile peritonitis: 1), which improved with antibiotic administration alone. Recurrent biliary obstruction (RBO) occurred in six patients (37.5%). Kaplan-Meier analysis revealed a 50% TRBO of 95 days (IQR 41-246 days). Endoscopic treatment was possible in all RBO cases, and repeat PTBD was not required.

CONCLUSIONS

Conversion of PTBD to EUS-BD for the management of MBO is both feasible and safe. This approach is expected to be widely practiced at centers with little experience in EUS-BD.

Lumen-apposing metals stents in advanced endoscopic ultrasound-guided interventions: novel applications, potential complications and radiologic assessment

Endoscopic ultrasound (EUS)-guided drainage procedures are an increasingly utilized minimally invasive alternative to percutaneous or surgical management strategies, having been shown to decrease recovery time, cost, and duration of hospital stay. The current mainstay of EUS-guided drainage procedures is in pancreatic and peripancreatic collections in pancreatitis. Recent technological advancements and the development of specialized stents have allowed for novel applications in a growing variety of clinical scenarios, including biliary obstruction, cholecystitis and gastrointestinal obstruction. An overview is provided of standard EUS-guided lumen-apposing metal stent (LAMS) management in pancreatic collections, including the expected radiologic findings and appropriate post-treatment sequelae. Relevant parameters to report include presence of a walled-off collection, collection contents, proximity of the target collection to the gastrointestinal lumen, intervening vascular structures or vascular malformations, and presence of regional cystic structures. Novel stent applications in biliary and gastrointestinal drainage are summarized and examples are provided, including choledochoduodenostomy in biliary obstruction, cholecystogastrostomy in cholecystitis, and jejunogastrostomy in focal gastrointestinal obstruction. Finally, a pictorial review of imaging findings of complications including perforation, hemorrhage, displacement, occlusion, migration and mistargeting is provided. Minimally invasive EUS-guided endoluminal stenting is utilized in a growing variety of clinical applications. Radiologist familiarity with common and novel applications of EUS-guided stenting is invaluable in determining suitability for endoscopic management, evaluating treatment response and identifying potential complications.