Endosonography-guided cholangiopancreatography as a salvage drainage procedure for obstructed biliary and pancreatic ducts

Manuel Perez-Miranda, Carlos de la Serna, Pilar Diez-Redondo, Endoscopy Unit. Hospital Universitario Rio Hortega, Valladolid 47012, Spain.
World journal of gastrointestinal endoscopy 06/2010; 2(6):212-22. DOI: 10.4253/wjge.v2.i6.212
Source: PubMed


Endoscopic ultrasound allows transmural access to the bile or pancreatic ducts and subsequent contrast injection to provide ductal drainage under fluoroscopy using endoscopic retrograde cholangiopancreatography (ERCP)-based techniques. Differing patient specifics and operator techniques result in six possible variant approaches to this procedure, known as endosonography-guided cholangiopancreatography (ESCP). ESCP has been in clinical use for a decade now, with over 300 cases reported. It has become established as a salvage procedure after failed ERCP in the palliation of malignant biliary obstruction. Its role in the management of clinically severe chronic/relapsing pancreatitis remains under scrutiny. This review aims to clarify the concepts underlying the use of ESCP and to provide technical tips and a detailed step-by-step procedural description.

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    • "Endoscopic retrograde cholangiopancreatography (ERCP) is the standard procedure for decompression of biliary and pancreatic ducts. Although the success rate is very high, it can fail in 3–10% of cases even by an experienced endoscopist [1] [2]. Percutaneous transhepatic cholangiography (PTC) [3] [4] and surgery [5] [6] have been the traditional alternatives. "
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    ABSTRACT: Endoscopic retrograde cholangiopancreatography (ERCP) can fail in 3-10% of the cases even in experienced hands. Although percutaneous transhepatic cholangiography (PTC) and surgery are the traditional alternatives, there are morbidity and mortality associated with both. In this paper, we have discussed the efficacy and safety of endoscopic-ultrasound-guided cholangiopancreatography (EUS-CP) in decompression of biliary and pancreatic ducts. The overall technical and clinical success rates are around 90% for biliary and 70% for pancreatic duct drainage. The overall EUS-CP complication rate is around 15%. EUS-CP is, however, a technically challenging procedure and should be performed by an experienced endoscopist skilled in both EUS and ERCP. Same session EUS-CP as failed initial ERCP is practical and may result in avoidance of additional procedures. With increasing availability of endoscopists trained in both ERCP and EUS, the role of EUS-CP is likely to grow in clinical practice.
    Full-text · Article · Mar 2013 · Gastroenterology Research and Practice
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    • "Finally, in cases where the guidewire crosses the downstream stricture antegradely, hepaticogastrostomy can be combined with antegrade placement of an additional metal stent bridging in the distal stricture, which further decreases the pressure gradient across the transmural stent by providing additional downstream decompression of the bile duct (6). Alternative strategies used by other authors to prevent migration include the placement of fully covered SEMS with both ends flared (7), or forceful balloon expansion upon stent deployment (as opposed to gradual spontaneous self-expansion over several hours) to monitor foreshortening and the insertion of a double pig-tail stent through the expanded SEMS in order to provide additional anchorage (8). "
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    ABSTRACT: To demonstrate a comprehensive review of published articles regarding endoscopic ultrasound (EUS)-guided biliary drainage. Review of studies regarding EUS-guided biliary drainage including case reports, case series and previous reviews. EUS-guided hepaticogastrostomy, coledochoduodenostomy and choledoantrostomy are advanced biliary and pancreatic endoscopy procedures, and together make up the echo-guided biliary drainage. Hepaticogastrostomy is indicated in cases of hilar obstruction, while the procedure of choice is the coledochoduodenostomy or choledochoantrostomy in distal lesions. Both procedures must be performed only after unsuccessful ERCPs. The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. Hepaticogastrostomy and coledochoduodenostomy or choledochoantrostomy are feasible when performed by endoscopists with expertise in biliopancreatic endoscopy. Advanced echo-endoscopy should currently be performed under a rigorous protocol in educational institutions.
    Full-text · Article · Apr 2012 · Korean journal of radiology: official journal of the Korean Radiological Society
    • "Kahaleh et al. described the advantages of EUS-guided hepaticogastrostomy vs percutaneous transhepatic drainage as: (1) less risk of bleeding by the use of coulour doppler to vaoid the puncture of vessels interposed between the gastric wall and the liver, (2) eliminated the presence of small amount of ascitis increasing the risk of bile leakage and choleperitoneum, and (3) difficulty of puncture in case of liver cirrhosis 4-risk of injuring the portal vein.10 "
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    ABSTRACT: 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.
    No preview · Article · Mar 2012
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