An Original Article from the July issue of GIE: “Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video)” by Do Hyun Park, MD, PhD, Seung Uk Jeong, MD, Byung Uk Lee, MD, Sang Soo Lee, MD, PhD, Dong-Wan Seo, MD, PhD, Sung Koo Lee, MD, PhD, Myung-Hwan Kim, MD, PhD
Dr. Do Hyun Park is an Associate Professor of Internal Medicine at the University of Ulsan College of Medicine at the Asan Medical Center in Seoul, Korea.
EUS-guided biliary drainage (EUS-BD) has been proposed as an alternative to percutaneous transhepatic biliary drainage (PTBD) in patients with biliary obstruction after failed ERCP. In terms of safety, EUS-guided rendezvous and antegade therapy seems to be safer than EUS-BD with bypass stenting. Because intraductal guidewire manipulation may be most difficult during procedures, most endoscopists may feel EUS-guided rendezvous and antegade therapy are technically difficult. Previous studies introduced accessible maneuvers for guidewire manipulation; however, these have not been integrated so far.
Therefore, we collected available guidewire manipulation maneuvers from published literature and modified them as an enhanced guidewire manipulation protocol. We then conducted this study with a treatment algorithm (guidewire manipulation protocol for rendezvous or antegrade therapy, EUS-BD with bypass stenting for duodenal invasion, or crossover to another approach if each technique failed) to reduce adverse events without sacrificing the technical success rate of EUS-BD.
Patient safety is the number one priority in all endoscopic procedures. Due to the lack of dedicated devices and standard protocol for EUS-BD, it is still challenging in terms of technical success and safety. Our prospective observation study showed outcomes of EUS-BD can be improved by various efforts. After a randomized controlled trial comparing EUS-BD and PTBD with standard protocol, EUS-BD may be a standard care of biliary decompression when ERCP is unsuccessful.
Figure 2. Intrahepatic approach. ERCP failed because of surgically altered anatomy (gastrojejunostomy and jejunojeunostomy for gastric outlet obstruction). A guidewire was placed in toward the hilum. A 4F cannula (Glo-Tip), used as a stiff instrument, was advanced through the fistula tract and into the left intrahepatic duct. Probing with the guidewire was performed under the guidance of the cannula. Finally, the guidewire could advance through major papilla, and anterograde biliary stenting was performed.
With our guidewire manipulation protocol, the rendezvous or antegrade therapy in more than half of our patients indicated that EUS-BD was treated, and eventually less EUS-BD with bypass stenting and a needle-knife for fistula dilation was performed. This may reduce adverse events in EUS-BD. Our study is the first prospective evaluation of EUS-guided rendezvous and antegrade biliary stenting/balloon dilation with our guidewire manipulation protocol as a first-line approach to EUS-guided biliary drainage. Thus, this study presented an actual clinical scenario to demonstrate how often EUS-guided rendezvous and antegrade biliary stenting/balloon dilation can be done instead of an EUS-BD. This treatment algorithm may be considered a potential standard study protocol for future randomized trials of EUS-BD and PTBD.
With dedicated devices and standard protocol for EUS-BD, this technique may be a primary role in patients with biliary obstruction in the near future.
Read the abstract for his article here.
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