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Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention

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Abstract

Background

Treatment of unresectable malignant hilar biliary stricture (UMHBS) is challenging, especially after failure of repeated transpapillary endoscopic stenting. Endoscopic ultrasonography-guided intrahepatic biliary drainage (EUS-IBD) is a recent technique for intrahepatic biliary decompression, but indications for its use for complex hilar strictures have not been well studied. The aim of this study was to assess the feasibility and safety of EUS-IBD for UMHBS after failed transpapillary re-intervention.

Methods

Retrospective analysis of all consecutive patients with UMHBS of Bismuth II grade or higher who, between December 2008 and May 2016, underwent EUS-IBD after failed repeated transpapillary interventions. The technical success, clinical success, and complication rates were evaluated. Factors associated with clinical ineffectiveness of EUS-IBD were explored.

Results

A total of 30 patients (19 women, median age 66 years [range 52–87]) underwent EUS-IBD for UMHBS during the study period. Hilar biliary stricture morphology was classified as Bismuth II, III, or IV in 5, 13, and 12 patients, respectively. The median number of preceding endoscopic interventions was 4 (range 2–14). EUS-IBD was required because the following procedures failed: duodenal scope insertion (n = 4), accessing the papilla after duodenal stent insertion (n = 5), or achieving desired intrahepatic biliary drainage (n = 21). Technical success with EUS-IBD was achieved in 29 of 30 patients (96.7%) and clinical success was attained in 22 of these 29 (75.9%). Mild peritonitis occurred in three of 30 (10%) and was managed conservatively. Stent dysfunction occurred in 23.3% (7/30). There was no procedure-related mortality. On multivariable analysis, Bismuth IV stricture predicted clinical ineffectiveness (odds ratio = 12.7, 95% CI 1.18–135.4, P = 0.035).

Conclusions

EUS-IBD may be a feasible and effective rescue alternative with few major complications after failed transpapillary endoscopic re-intervention in patients with UMHBS, particularly for Bismuth II or III strictures.

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Acknowledgements

This study was supported by grants from the Japan Society for Promotion of Science.

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Authors and Affiliations

  1. Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan

    Kosuke Minaga, Mamoru Takenaka, Hajime Imai, Kentaro Yamao, Ken Kamata, Takeshi Miyata, Shunsuke Omoto, Toshiharu Sakurai, Tomohiro Watanabe, Naoshi Nishida & Masatoshi Kudo

  2. Second Department of Internal Medicine, School of Medicine, Wakayama Medical University, Wakayama, Japan

    Masayuki Kitano

  3. Clinical Research Center, Kindai University Hospital, Osaka-Sayama, Japan

    Yasutaka Chiba

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  1. Kosuke Minaga
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Correspondence to Mamoru Takenaka.

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Dr. Kosuke Minaga, Dr. Mamoru Takenaka, Dr. Masayuki Kitano, Dr. Yasutaka Chiba, Dr. Hajime Imai, Dr. Kentaro Yamao, Dr. Ken Kamata, Dr. Takeshi Miyata, Dr. Shunsuke Omoto, Dr. Toshiharu Sakurai, Dr. Tomohiro Watanabe, Dr. Naoshi Nishida, and Dr. Masatoshi Kudo have no conflicts of interest or financial ties to disclose.

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Minaga, K., Takenaka, M., Kitano, M. et al. Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention. Surg Endosc 31, 4764–4772 (2017). https://doi.org/10.1007/s00464-017-5553-6

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