Authors M. BRONSWIJK (1), G. VANELLA (1), H. VAN MALENSTEIN (1), W. LALEMAN (1), S. VAN DER MERWE (1) / [1] University Hospitals Leuven, , Belgium, Department of Gastroenterology and Hepatology
Introduction Intrahepatic access for EUS-guided biliary drainage (IH-EBD) has demonstrated its feasibility, but still lacks convincing evidence on advantages and risks over comparators. Mainly retrospective series are burdened by small size, heterogeneous inclusion of patients and analysis of miscellaneous procedures, IH-EBD therefore struggles to find a role in clinical algorithms.
Aim Our aim was to retrospectively analyse an 8-year tertiary centre experience with this technique and compare indications, efficacy and safety between different IH-EBD approaches.
Methods All consecutive IH-EBD executed in one tertiary referral centre between 2012 and 2019 were retrospectively included. Indications, technical details, clinical/biochemical parameters and events during follow-up were extracted from individual patient files. Variables are expressed as proportions and median [interquartile range]. Χ-squared, Mann-Whitney U and Kruskal-Wallis test were used for comparisons as appropriate. Kaplan-Meier estimates were used for the stent dysfunction-free survival analysis.
Results In this time interval, 104 IH-EBD were performed (malignancy: n=87 (83.7%); previously failed ERCP: n=81 (77.9%); altered surgical anatomy: n=23 (22.1%). Distal, hilar and anastomotic strictures represented 50%, 28.9% and 14.4% of indications. Sixteen transhepatic ERCP-rendez-vous procedures (RVs), 43 transhepatic antegrade biliary stentings (ASs) and 45 hepatico-gastrostomies (HGs) were identified. Seventeen [38%] HGs were executed with specifically-designed half-covered stents. Overall technical success was 89.4%, whilst clinical success (lowering bilirubin or management of choledocholithiasis) was 94%. Using the ASGE lexicon, overall, severe and fatal complication rates were 16.7%, 3.0% and 0.9% respectively. Median hospital stay was 7 [2-10] days and in case of no complications, 4.5 [1-9] days. Stent dysfunction occurred in 17.1% after a median of 103.5 [42.5-168.0] days, resulting in a 72% probability of 6-months dysfunction-free survival. When comparing the three techniques, benign diseases were more prevalent among RVs (p=0.0004), while hilar/anastomotic strictures were mainly managed through HGs (p<0.0001). Technical failures were higher among RVs compared to ASs or HGs (25% vs. 4.4% and 11.6% respectively, p=0.036). Per-protocol clinical success was equivalently high. There was a trend toward a lesser extent of bilirubin decrease in the HG group (53.3% of cases experienced >50% decrease, compared to 66.7% and 96% in the RV and AS groups; p=0.007), which may be attributed to a significantly higher rate of disconnected ducts amongst HGs (53.5% vs. 6.2 and 2.2%, p<0.0001). No difference in severe adverse events was seen. Stent dysfunction was identified in 25%, 12.5% and 20.6% of RVs, ASs and HGs respectively (p=0.624), with a trend towards reduced stent dysfunction when HGs were created with purpose-specific stents vs. older stents (6.7% vs. 31.6%, p=0.0789).
Conclusions The intrahepatic route for EUS-guided biliary drainage in failed ERCPs or surgically altered anatomy has a good clinical efficacy, relatively low dysfunction rate and an acceptable safety profile. While distal stenoses can also be managed through the extra-hepatic EUS-guided access, these results are particularly valuable for indications in which the only alternative would be percutaneous drainage. Increased technical expertise, specifically designed tools and high-quality comparisons are compelling for a standardized inclusion of this technique in the endoscopic armamentarium of tertiary referral centers.
