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 Table of Contents  
COMMENTARY
Year : 2019  |  Volume : 8  |  Issue : 7  |  Page : 14-16

De novo EUS-guided biliary drainage


Department of Gastroenterology, Aichi Cancer Center, Nagoya, Japan

Date of Submission11-Jun-2019
Date of Acceptance08-Jul-2019
Date of Web Publication28-Nov-2019

Correspondence Address:
Dr. Kazuo Hara
Department of Gastroenterology, Aichi Cancer Center, Nagoya
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_48_19

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How to cite this article:
Hara K, Okuno N, Yamao K. De novo EUS-guided biliary drainage. Endosc Ultrasound 2019;8, Suppl S1:14-6

How to cite this URL:
Hara K, Okuno N, Yamao K. De novo EUS-guided biliary drainage. Endosc Ultrasound [serial online] 2019 [cited 2019 Dec 6];8, Suppl S1:14-6. Available from: http://www.eusjournal.com/text.asp?2019/8/7/14/271808




  Introduction Top


EUS-guided biliary drainage (EUS-BD) was developed as a rescue method of ERCP.

Recently, the usefulness of EUS-BD for the papilla tumors, duodenal stenosis by tumors, or altered anatomy patients were reported in many papers. EUS-BD is a good indication for difficult ERCP cases. In addition, “de novo EUS-BD” for malignant lower biliary obstructions is focused by experienced endosonographers now. The most different points in these two procedures are kinds of complications. Post-ERCP pancreatitis is a big problem in ERCP until now. All physicians made efforts to decrease post-ERCP pancreatitis for very long time, but still unresolved. EUS-BD is very low risk of pancreatitis, nearly zero. However, bile peritonitis is a common complication of EUS-BD. Which is the better procedure for malignant lower biliary obstructions?

Hence, in this review, we will focus on de novo EUS-BD, not a rescue of the standard transpapillary drainage for lower biliary obstructions. We will not mention about de novo EUS-BD for hilar obstructions which is still controversial because of not enough evidence.


  Results in Published Papers Top


The possibility of de novo EUS-BD was reported from the early stages of the development. First report of the primary EUS-BD was EUS-guided choledochoduodenostomy (EUS-CDS) cases enrolled in the prospective study by Hara et al., in 2011.[1] First prospective study of focusing de novo EUS-BD was also reported in 2013 by Hara et al.[2] Results of these two papers showed clinical usefulness in de novo EUS-BD. Okuno et al. reported usefulness of primary EUS-guided hepaticogastrostomy (EUS-HGS) for estimated difficult ERCP cases.[3] They also reported the safety of 6 mm bore fully covered metal stents. Kawakubo et al.[4] and Nakai et al.[5] published papers of comparative studies in EUS-CDS and ERCP. They reported EUS-CDS is the acceptable procedure compared with ERCP. Three randomizes controlled trial papers[6],[7],[8] referred to EUS-BD vs. ERCP were already published in 2018. Bang et al.[8] and Park et al.[6] reported ERCP vs. EUS-CD. Paik et al.[7] reported ERCP vs. EUS-BD (both EUS-HGS and EUS-CDS). Park et al.[6] reported EUS-BD had similar safety to ERCP. They also reported EUS-BD was not superior to ERCP in terms of relief of malignant biliary obstruction. EUS-BD may have fewer cases of tumor ingrowth but may also have more cases of food impaction or stent migration. Bang et al.[8] reported the similar rates of adverse events and treatment outcomes in the randomized trial. They also mentioned EUS-BD was a practical alternative to ERCP for primary biliary decompression in pancreatic cancer. Paik et al.[7] reported comparable technical and clinical success rates between EUS-BD and ERCP in relief malignant distal biliary obstruction. Substantially, longer duration of patency coupled with lower rates of adverse events and reintervention, and more preserved quality of life (QOL) were observed with EUS-BD.

Total early adverse events rate in published papers is 12% (23/199) in the present paper. Technical and clinical success rate are both 95% in the present paper [Table 1].
Table 1: Published papers (de novo EUS-biliary drainage)

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  Discussion Top


From the published papers, de novo EUS-BD has a comparable technical success rate, clinical success rates, and safety. Stent patency of EUS-BD may be longer than ERCP. EUS-BD may have the benefits in reintervention and patient's QOL also. The most different and beneficial point in de novo EUS-BD is zero pancreatitis. Zero pancreatitis is so happy for both patients and physicians. Until now, we cannot prevent post-ERCP pancreatitis, so EUS-BD is the ideal procedure at this point. Bile peritonitis is a common complication in EUS-BD; this is the unresolved problem also. Can we decrease these two complications in future? If dedicated devices are developed, EUS-BD can decrease severe complications, especially bile leakage. One step devices such as Hot AXIOS[9] may prevent bile leakage and other complications also. We can minimize complications of EUS-BD by ourselves. However, ERCP is not in the same condition. Even if ERCP devices are so developed in the near future, we cannot easily prevent pancreatitis. A long history of ERCP can show this fact. Only one way of the prevention pancreatitis is “no touch the papilla.”

The second beneficial point in de novo EUS-BD is the new drainage route. EUS-BD creates the new drainage route outside the tumor. On the other hand, ERCP put the stent into the tumor. In the clinical course, tumors will involve ERCP stent and duodenum. Reintervention of ERCP may be difficult in this situation. On the other hand, EUS-BD stent is located above the tumor, so sent dysfunction by the tumor progression is not so common.[7] Reintervention of EUS-BD is much easier than ERCP.[3] Ascites are commonly seen in advanced malignant patients. After pooling ascites, EUS-BD is not a safe procedure due to the possibility of infectious peritonitis. Hence, finally, we recommend the early stage EUS-BD, especially de novo EUS-BD before pooling ascites and duodenal obstruction.

However, some physicians do not agree the de novo EUS-BD.[10] Because EUS-BD is a still not matured procedure. There are no good teaching system and few good trainers in these fields. Hence, the clinical benefits of de novo EUS-BD are still controversial.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hara K, Yamao K, Niwa Y, et al. Prospective clinical study of EUS-guided choledochoduodenostomy for malignant lower biliary tract obstruction. Am J Gastroenterol 2011;106:1239-45.  Back to cited text no. 1
    
2.
Hara K, Yamao K, Hijioka S, et al. Prospective clinical study of endoscopic ultrasound-guided choledochoduodenostomy with direct metallic stent placement using a forward-viewing echoendoscope. Endoscopy 2013;45:392-6.  Back to cited text no. 2
    
3.
Okuno N, Hara K, Mizuno N, et al. Efficacy of the 6-mm fully covered self-expandable metal stent during endoscopic ultrasound-guided hepaticogastrostomy as a primary biliary drainage for the cases estimated difficult endoscopic retrograde cholangiopancreatography: A prospective clinical study. J Gastroenterol Hepatol 2018;33:1413-21.  Back to cited text no. 3
    
4.
Kawakubo K, Kawakami H, Kuwatani M, et al. Endoscopic ultrasound-guided choledochoduodenostomy vs. transpapillary stenting for distal biliary obstruction. Endoscopy 2016;48:164-9.  Back to cited text no. 4
    
5.
Nakai Y, Isayama H, Kawakami H, et al. Prospective multicenter study of primary EUS-guided choledochoduodenostomy using a covered metal stent. Endosc Ultrasound 2019;8:111-7.  Back to cited text no. 5
    
6.
Park JK, Woo YS, Noh DH, et al. Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: Prospective randomized controlled study. Gastrointest Endosc 2018;88:277-82.  Back to cited text no. 6
    
7.
Paik WH, Lee TH, Park DH, et al. EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: A multicenter randomized clinical trial. Am J Gastroenterol 2018;113:987-97.  Back to cited text no. 7
    
8.
Bang JY, Navaneethan U, Hasan M, et al. Stent placement by EUS or ERCP for primary biliary decompression in pancreatic cancer: A randomized trial (with videos). Gastrointest Endosc 2018;88:9-17.  Back to cited text no. 8
    
9.
Tsuchiya T, Teoh AY, Itoi T, et al. Long-term outcomes of EUS-guided choledochoduodenostomy using a lumen-apposing metal stent for malignant distal biliary obstruction: A prospective multicenter study. Gastrointest Endosc 2018;87:1138-46.  Back to cited text no. 9
    
10.
Nabi Z, Talukdar R, Reddy DN. Primary EUS-guided drainage for malignant distal biliary obstruction: Not yet prime time! Gastrointest Endosc 2018;88:18-20.  Back to cited text no. 10
    



 
 
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