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 Table of Contents  
Year : 2017  |  Volume : 6  |  Issue : 9  |  Page : 127-131

Therapeutic EUS: Biliary drainage - The interventional radiologist's perspective

Department of Radiology and Experimental Imaging Centre, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy

Date of Submission12-Jul-2017
Date of Acceptance31-Aug-2017
Date of Web Publication29-Dec-2017

Correspondence Address:
Dr. Francesco De Cobelli
Department of Radiology and Experimental Imaging Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, via Olgettina 60, 20132 Milan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_77_17

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How to cite this article:
De Cobelli F, Marra P, Diana P, Brembilla G, Venturini M. Therapeutic EUS: Biliary drainage - The interventional radiologist's perspective. Endosc Ultrasound 2017;6, Suppl S3:127-31

How to cite this URL:
De Cobelli F, Marra P, Diana P, Brembilla G, Venturini M. Therapeutic EUS: Biliary drainage - The interventional radiologist's perspective. Endosc Ultrasound [serial online] 2017 [cited 2021 Jan 16];6, Suppl S3:127-31. Available from: http://www.eusjournal.com/text.asp?2017/6/9/127/221946

  Biliary Decompression in Pancreatic Cancer Top

Up to 75% of patients with pancreatic cancer develop symptomatic biliary obstruction [1] and both the most recent guidelines from the European Society of Medical Oncology (ESMO)[2] and the National Comprehensive Cancer Network (NCCN) strongly recommend the endoscopic approach for the placement of a metallic biliary stent. Although biliary drainage (BD) is strongly recommended as palliation in advanced pancreatic cancer to provide relief of biliary and/or duodenal obstruction, malnutrition, and pain,[2] studies do not recommend presurgical BD.[3],[4] However, based on the most recent evidence, including a randomized controlled trial, both the ESMO and NCCN guidelines suggest routine preoperative BD only in selected patients with symptomatic jaundice, cholangitis, or with an expected delay to surgery.[2],[5],[6]

The endoscopic method is the first-line treatment for biliary obstruction. A recent study compared endoscopic and percutaneous drainage in a population of 9135 patients from the Nationwide Inpatient Sample;[7] it showed that endoscopic BD through endoscopic retrograde cholangiopancreatography (ERCP) has fewer adverse events compared to the percutaneous approach for malignant biliary tract obstruction (8.6% vs. 12.3%; P < 0.001), even considering only the pancreatic cancer subgroup (2.9% vs. 6.2%; P < 0.001). Despite this, the results of another meta-analysis have found a better outcome, although no significant, in favor of percutaneous biliary drainage (PTBD) over ERCP in the drainage of malignant biliary obstruction.[8]

ERCP is limited in cases of gastric outlet or duodenal obstruction not susceptible for endoscopic dilation and enteral stenting and in cases of postsurgical altered gastrointestinal anatomy (Roux-en-Y gastric bypass, Kausch–Whipple resection, pylorus-preserving Whipple resection, Roux-en-Y hepaticojejunostomy, choledochojejunostomy, and pancreaticojejunostomy), while patients with a previously performed surgical Billroth I and II gastrectomy may be not an issue for conventional ERCP.[9] When ERCP fails, PTBD with subsequent internalization may be necessary. PTBD is a well-recognized treatment modality in the management of biliary obstruction and above all in cases of failure of the endoscopic approach and altered gastrointestinal anatomy. There is no absolute contraindication for PTBD, and relative contraindications are limited to coagulation disorders, allergy to iodinated contrast agents, and ascites;[10] coagulopathy may be corrected or adjusted before the procedure, and an allergic reaction can be prevented.

An alternative method to PTBD is endoscopic ultrasound-guided BD (EUS-BD).[11],[12] There is growing evidence that the EUS-guided approach is comparable to PTBD in terms of efficacy and safety.[13],[14],[15],[16],[17],[18] However, its application is available only in a few centers and significant expertise is required to perform reliable examinations. Currently, it has not yet found a recommendation, and randomized controlled trials are required to further evaluate its efficacy and safety in comparison with the traditional modalities.[19]

  Standards of Practice for Percutaneous Transhepatic Cholangiography Top

Before any procedure, patients should undergo multiphase contrast-enhanced computed tomography and/or magnetic resonance imaging with magnetic resonance cholangiopancreatography. PTBD should never be performed without a proper noninvasive evaluation of the biliary tree.[20]

In accordance with the “quality improvement guidelines for percutaneous transhepatic cholangiography and biliary drainage”[21] published by the Society of Interventional Radiology and shared by the Cardiovascular and Interventional Society of Europe, the threshold of technical success rates after PTBD should be as high as 95% and 70%–80% in cases of dilated and nondilated bile ducts, respectively. To improve the procedure success rate, especially in patients with nondilated ducts and for the left-sided approach, ultrasound (US) guidance should be considered.[9] Reported rates of clinical success, defined as the resolution of symptoms, are above 75%;[20] to improve the clinical outcome the radiologist should monitor and manage the patient who has undergone PTBD.

One of the main advantages of PTBD over ERCP is the possibility of avoiding cannulation of the papilla, virtually nullifying the risk of acute pancreatitis, especially in surgical patients.[22] When ERCP is performed, the risk of developing pancreatitis is about 3.5%;[23] however, in some studies, rates reached up to 15.7%.[24] Moreover, in our opinion, percutaneous cholangiography allows a clearer representation of the biliary tree and a better comprehension of anatomic variants, than ERCP. This is particularly relevant in case of abnormal insertion of biliary ducts that, if not detected and are excluded by the placement of covered stents, may evolve to cholangitis.

Adverse events include hemorrhage (1.42%), biliary leak (1.42%), sepsis (6.25% including abscess, peritonitis, pancreatitis), and recurrence of obstructive jaundice (3.27%).[22] Most of the complications are immediate and are treated conservatively or by interventional radiology. According to “quality improvement guidelines,” the ceiling for all major complications of percutaneous transhepatic BD should be 10%; centers with higher complication rates should make an internal review of methods and procedures.[21]

For distal obstructions, right-sided procedures are preferred, since left-sided PTBD is associated with a slight, but no significant increase in clinically relevant hemobilia of 1.5%–5.2%.[9] Internal/external tubes may present problems related to inadequate bile flow or dislodgement, leading to septic complications and hemorrhage; these risks can be minimized with 8-10 Fr locking catheters placed through the ampulla or anastomosis. Appropriate antibiotics should be administered before initiating the procedures to prevent sepsis, and the duration of antibiotic therapy should be tailored on the clinical course of individual patients.[21] With the percutaneous approach, in addition to internal/external drainage, a biliary stent can be placed. An uncovered self-expandable metal stent is the most common, with or without balloon (pre-) dilatation and with the distal end going across the papilla. This improves BD and reduces the risk of postprocedure cholangitis. A transprosthesis internal/external 8 Fr tube (or a smaller catheter) is left along the percutaneous/transhepatic track for the first 48–72 h following stent placement to minimize the risk of postprocedure biliary sepsis and bleeding from the liver capsule at the puncture site. In case of stent obstruction, due to biliary sludge or tumor growth, PTBD can be repeated with a coaxial metal stent placement.[22]

Procedure-related death has been reported with rates of up to 5.6% in an old published series,[22] but technical improvements and implementation of US guidance for bile duct puncture have dramatically reduced the rates of morbidity and mortality.[25] However, the “standard of practice” suggests a threshold for mortality of 3%, which, in our opinion, is still too high to be tolerated.

  How to Improve Percutaneous Biliary Drainage Top

We analyzed multiple aspects that should be improved for a better PTBD outcome. First of all, the use of US for puncture guidance [Figure 1] reduces the risk of hemorrhage and pleural transgression, preventing pneumothorax, hemothorax, and biliary pleural effusions.[25] Patient selection and classification by risk stratification can also be useful to predict rates of possible complications, and sometimes, can intervene where possible to reduce risks.[22] As for ERCP procedures, where in high volume centers, each endoscopist performs >25 ERCP per year,[26] we should reserve the performance of PTBD only to such specialized centers, since in a comparison of PTBD performed in centers with low and high volumes, the rates of adverse events are significantly different (P = 0.001), 7.61% and 5.62%, respectively.[7] Ultimately, a preoperative anesthesiologic evaluation, perioperative support and dedicated materials and devices can also change the outcome of the procedure.
Figure 1: A case of percutaneous biliary drainage after failed endoscopic retrograde cholangiopancreatography and iatrogenic pancreatitis. (a) The puncture of an intrahepatic bile duct under ultrasound guidance (the white arrow indicates the tip of the Chiba needle). Percutaneous cholangiography (b) depicts the biliary tree allowing guidewire insertion (through the Chiba needle, black arrow) and catheterization of the common bile duct and duodenum (c). Intrahepatic bile ducts and the common bile duct are dilated with narrowing of the intrapancreatic bile duct (black arrow in c). (d) Successful biliary decompression

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  Future Perspectives Top

The latest generation of flexible fiberoptic choledochoscopes has increased the interest of interventional radiologists for direct visual exploration of the biliary tree; under direct vision, it is possible to perform bioptic sampling and narrow differential diagnosis of biliary strictures. With modern equipment and flexible fiberoptic choledochoscopes, the percutaneous transhepatic access is limited to 9–10 Fr and the complication rate of cholangioscopy does not exceed that of PTBD.[27] Rather than in the first-line treatment of patients with pancreatic cancer, this method finds more application for upper biliary tract diseases, in patients with previous surgeries, and/or altered gastrointestinal anatomy.

  Percutaneous Biliary Drainage at Large-Volume Center Top

In 2016, in our institution, considered of high volume according to ERCP considerations (defined as >25/year/interventional radiologist), four interventional radiologists performed 128 percutaneous transhepatic BDs; each interventional radiologist performed about 32.5 PTBD per year.[26] Our results are comparable with those of recently published series. Technical success was reached in 125 cases (98%); 42 of 128 cases presented with a previously failed ERCP; in this subgroup, technical success was 100%, and a percutaneous drainage or an uncovered self-expandable metal stent was placed respectively in 30 and 12 cases. Forty-six patients presented altered anatomy due to previous surgery and were not eligible for ERCP, one of which underwent a Rendezvous technique. A Rendezvous approach was also applied in two other patients with normal anatomy after a failed ERCP. No deaths due to PTBD complications were recorded. Of note, no cases of clinically relevant pancreatitis were observed. Cases of hemorrhage were successfully managed with intra-arterial embolization by the same interventional radiologists. Septic adverse events were managed with intravenous antibiotics and positioning of larger internal/external catheters (10–12 Fr), with a resolution of symptoms. Annual clinical records of PTBD in our institution are shown in [Table 1].
Table 1: Annual clinical records of percutaneous biliary drainage in our institution

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  Conclusion Top

In patients with pancreatic cancer presenting with distal biliary obstruction, the first-line treatment should be endoscopic. In case of failed ERCP, the PTBD is a valid method that presents a low complication rate, with even better rates when performed in high-volume centers. Furthermore, the US-guided percutaneous puncture reduces complications, that are mostly treated conservatively or in the interventional radiology (IR) theater. An alternative to PTBD may be EUS-guided BD, but this approach still lacks sufficient evidence to be applied on a large scale; prospective robust randomized trials are necessary. In conclusion, in large volume center with qualified interventional radiologists, in case of ERCP unfeasibility or failure, we still recommend the percutaneous approach, favored by higher rates of technical success and lower rates of complications.

  References Top

House MG, Choti MA. Palliative therapy for pancreatic/biliary cancer. Surg Clin North Am 2005;85:359-71.  Back to cited text no. 1
Ducreux M, Cuhna AS, Caramella C, et al. Cancer of the pancreas: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015;26 Suppl 5:v56-68.  Back to cited text no. 2
Sewnath ME, Karsten TM, Prins MH, et al. Ameta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002;236:17-27.  Back to cited text no. 3
van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 2010;362:129-37.  Back to cited text no. 4
Moole H, Bechtold M, Puli SR. Efficacy of preoperative biliary drainage in malignant obstructive jaundice: A meta-analysis and systematic review. World J Surg Oncol 2016;14:182.  Back to cited text no. 5
Sugiyama H, Tsuyuguchi T, Sakai Y, et al. Current status of preoperative drainage for distal biliary obstruction. World J Hepatol 2015;7:2171-6.  Back to cited text no. 6
Inamdar S, Slattery E, Bhalla R, et al. Comparison of adverse events for endoscopic vs. percutaneous biliary drainage in the treatment of malignant biliary tract obstruction in an inpatient national cohort. JAMA Oncol 2016;2:112-7.  Back to cited text no. 7
Zhao XQ, Dong JH, Jiang K, et al. Comparison of percutaneous transhepatic biliary drainage and endoscopic biliary drainage in the management of malignant biliary tract obstruction: A meta-analysis. Dig Endosc 2015;27:137-45.  Back to cited text no. 8
Dietrich CF, Lorentzen T, Appelbaum L, et al. EFSUMB guidelines on interventional ultrasound (INVUS), Part III – abdominal treatment procedures (Long version). Ultraschall Med 2016;37:E1-32.  Back to cited text no. 9
Madhusudhan KS, Gamanagatti S, Srivastava DN, et al. Radiological interventions in malignant biliary obstruction. World J Radiol 2016;8:518-29.  Back to cited text no. 10
Artifon EL, Perez-Miranda M. EUS-guided choledochoduodenostomy for malignant distal biliary obstruction palliation: An article review. Endosc Ultrasound 2012;1:2-7.  Back to cited text no. 11
Artifon EL, Loureiro JF, Baron TH, et al. Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure. Endosc Ultrasound 2015;4:235-43.  Back to cited text no. 12
Wang K, Zhu J, Xing L, et al. Assessment of efficacy and safety of EUS-guided biliary drainage: A systematic review. Gastrointest Endosc 2016;83:1218-27.  Back to cited text no. 13
Moole H, Bechtold ML, Forcione D, et al. A meta-analysis and systematic review: Success of endoscopic ultrasound guided biliary stenting in patients with inoperable malignant biliary strictures and a failed ERCP. Medicine (Baltimore) 2017;96:e5154.  Back to cited text no. 14
Sharaiha RZ, Khan MA, Kamal F, et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: A systematic review and meta-analysis. Gastrointest Endosc 2017;85:904-14.  Back to cited text no. 15
Baniya R, Upadhaya S, Madala S, et al. Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage after failed endoscopic retrograde cholangiopancreatography: A meta-analysis. Clin Exp Gastroenterol 2017;10:67-74.  Back to cited text no. 16
Lee TH, Choi JH, Park do H, et al. Similar efficacies of endoscopic ultrasound-guided transmural and percutaneous drainage for malignant distal biliary obstruction. Clin Gastroenterol Hepatol 2016;14:1011-9.e3.  Back to cited text no. 17
Bapaye A, Dubale N, Aher A. Comparison of endosonography-guided vs. Percutaneous biliary stenting when papilla is inaccessible for ERCP. United European Gastroenterol J 2013;1:285-93.  Back to cited text no. 18
Khan MA, Akbar A, Baron TH, et al. Endoscopic ultrasound-guided biliary drainage: A systematic review and meta-analysis. Dig Dis Sci 2016;61:684-703.  Back to cited text no. 19
van Delden OM, Laméris JS. Percutaneous drainage and stenting for palliation of malignant bile duct obstruction. Eur Radiol 2008;18:448-56.  Back to cited text no. 20
Saad WE, Wallace MJ, Wojak JC, et al. Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol 2010;21:789-95.  Back to cited text no. 21
Tapping CR, Byass OR, Cast JE. Percutaneous transhepatic biliary drainage (PTBD) with or without stenting-complications, re-stent rate and a new risk stratification score. Eur Radiol 2011;21:1948-55.  Back to cited text no. 22
Dumonceau JM, Andriulli A, Elmunzer BJ, et al. Prophylaxis of post-ERCP pancreatitis: European society of gastrointestinal endoscopy (ESGE) guideline – Updated June 2014. Endoscopy 2014;46:799-815.  Back to cited text no. 23
Szary NM, Al-Kawas FH. Complications of endoscopic retrograde cholangiopancreatography: How to avoid and manage them. Gastroenterol Hepatol (N Y) 2013;9:496-504.  Back to cited text no. 24
Wagner A, Mayr C, Kiesslich T, et al. Reduced complication rates of percutaneous transhepatic biliary drainage with ultrasound guidance. J Clin Ultrasound 2017;45:400-7.  Back to cited text no. 25
Coté GA, Imler TD, Xu H, et al. Lower provider volume is associated with higher failure rates for endoscopic retrograde cholangiopancreatography. Med Care 2013;51:1040-7.  Back to cited text no. 26
Ahmed S, Schlachter TR, Hong K. Percutaneous transhepatic cholangioscopy. Tech Vasc Interv Radiol 2015;18:201-9.  Back to cited text no. 27


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