EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos).

BACKGROUND: Percutaneous transhepatic biliary drainage (PTBD) may be the last resort for an occluded biliary metal stent when the ERCP was unsuccessful. OBJECTIVE: Because an EUS-guided biliary drainage has been proposed as an effective alternative for PTBD after a failed ERCP, we conducted this study to determine the feasibility and usefulness of an EUS-guided hepaticogastrostomy (EUS-HG) with a fully covered self-expandable metal stent (FCSEMS) for an occluded biliary metal stent after a failed ERCP. DESIGN: A case study. SETTING: A tertiary referral center. PATIENTS AND INTERVENTIONS: Five patients who had an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion and for whom reinterventional ERCP was unsuccessful underwent an EUS-HG with an FCSEMS for alternative PTBD. MAIN OUTCOME MEASUREMENTS: Technical and functional success, procedural complications, reinterventional rate after EUS-HG with an FCSEMS, and short-term stent patency. RESULTS: In all 5 patients, an EUS-HG with an FCSEMS was technically successful. No procedural complications, such as bile peritonitis, cholangitis, and pneumoperitoneum, were observed. Functional success was also 100% (5/5). During the follow-up period (median 152 days, range 64-184 days), no late complications, such as stent migration and occlusion, were observed. Thus, no biliary reintervention was performed during the follow-up period. LIMITATIONS: A small series of patients without a control group. CONCLUSIONS: The EUS-HG with an FCSEMS may be feasible, effective, and an alternative PTBD for an occluded biliary metal stent after a failed ERCP.

Management of unresectable hilar bile duct cancer--preoperative diagnosis, treatment selection, and clinical outcome.

BACKGROUND/AIMS: Hilar bile duct cancer progresses slowly but easily invades the nearby portal vein or hepatic artery. Thus, in some cases, curative resection is impossible, so we need to determine the best non-surgical treatments for this tumor. METHODOLOGY: We classified 98 patients with hilar bile duct cancer into 3 categories: a non-surgical group (34 cases), an exploratory laparotomy group (9 cases), and a surgical resection group (55 cases). Survival rates were examined in the light of clinical factors. RESULTS: In the non-surgical group, extensive vessel invasion was the most common reason for unresectability (13 cases), with broad biliary extension the second most common (11 cases). In the exploratory laparotomy group the most common reason for unresectability was severe vessel invasion (6 cases). Cumulative 1- and 2-year survival rates for patients with unresectable tumors without distant metastasis were 26.9% and 7.2%, respectively. One- and 2-year survival rates for patients with unresectable tumors and with total bilirubin of less than 2 mg/dL on discharge were 36.8% and 9.8%, respectively. The 1-year survival rate with placement of an expandable metallic stent was as high as 55.6%; without the stent it was 7.1% (P = 0.005). Radiation therapy gave a better prognosis than did no radiation (P = 0.01). CONCLUSIONS: Portal and arterial invasion were the principal reasons for unresectability. Use of an expandable metallic stent or radiation therapy, and a total bilirubin level of less than 2 mg/dL on discharge, were factors that enhanced survival in unresectable cases, but distant metastasis, dissemination, and poor general condition or liver function were negative factors for survival.

Therapeutic alternatives in the treatment of intrahepatic biliary obstruction.

Intrahepatic biliary obstruction was treated in 60 patients (49 with cholangiocarcinoma and 11 with sclerosing cholangitis) who were classified according to the upper limit of their obstruction (Group I, proximal common hepatic duct; Group 2, right and left main hepatic ducts; Group 3, intrahepatic bile ducts). Thirty-six patients underwent percutaneous transhepatic biliary drainage, and 14 underwent catheterization through a T-tube track, Five of this latter group had the T-tube placed to establish a route of access for later interventional radiologic manipulations. Since most diseases that produce intrahepatic biliary obstruction are progressive, the use of any single approach is limited. The advantages of a surgically created route of access combined with the flexibility of interventional radiologic techniques help to maximize the therapy and extend the palliation that many of these patients receive.