Stenting: Partially covered wallstent 6 cm (Boston Scientific. Corporation, Natick, MA, USA). Backround and Endoscopic Procedure. A 64-year-old man was ...
Endoscopic Ultrasound-Guided Choledochoduodenostomy (EUCD) U Will, Medizinische Klinik 3, Gera, Germany r 2013 Elsevier GmbH. Open access under CC BY-NC-ND license. Received 30 June 2012; Revision submitted 13 August 2012; Accepted 13 August 2012
Abstract In patients with jaundice and unsuccessful biliary drainage with cholangiopancreatography because of inaccessible papilla due to duodenal stenosis caused by tumor invasion, endoscopic ultrasound (EUS)-guided biliary drainage has been introduced as an alternative to percutaneous cholangiodrainage (PTCD). Here is demonstrated an EUS-guided choledochoduodenostomy in a patient with local advanced pancreatic carcinoma. This article is part of an expert video encyclopedia.
Keywords Endoscopic ultrasound; EUS-guided biliary drainage; EUS-guided choledochoduodenostomy; Video.
Video Related to this Article Video available to view or download at doi:10.1016/S22120971(13)70209-7
Techniques Endosonography, fluoroscopy, and cholangiography.
Materials
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Endosonography: EG 3870UTK (Hitachi Medical System, Tokyo, Japan). Puncture: 19-gauge needle (Boston Scientific Corporation, Natick, MA, USA). Probing: 0.0035 in. guidewire (Boston Scientific Corporation, Natick, MA, USA). Choledochostomy J Ring knife ‘Dr. Will’ (MTW-Endoskopie, Wesel, Germany). J MaxForce balloon (Boston Scientific Corporation, Natick, MA, USA). Stenting: Partially covered wallstent 6 cm (Boston Scientific Corporation, Natick, MA, USA).
Backround and Endoscopic Procedure A 64-year-old man was admitted for cholestasis and fever. The patient had a gastrojejunostomy 2 months earlier because of local advanced tumor in the head of the pancreas with stenosis of the distal duodenum. At this time jaundice was absent, so the surgeon passed on hepaticojejunostomy. Abdominal sonography showed dilated intrahepatic bile ducts and a dilated common bile duct. A cholangiopancreatography (ERCP) This article is part of an expert video encyclopedia. Click here for the full Table of Contents.
Video Journal and Encyclopedia of GI Endoscopy
was impossible because of the stenotic descending duodenum and the inaccessible papilla. When ERCP is unsuccessful, the usual alternative is percutaneous transhepatic biliary drainage. However, PTCD may be associated with complications such as bleeding and bile leakage. If subsequent internal drainage cannot be achieved, the patient would have to accept long-term external biliary drainage, which can be uncomfortable and is nonphysiological, with significant impairment of quality of life. In cases where internal biliary access with ERCP cannot be achieved, interventional endoscopic ultrasound (EUS)-guided cholangiodrainage has become an alternative to percutaneous transhepatic cholangiodrainage.1–4 In this patient, EUS-guided biliary drainage was performed under conscious sedation using a combination of intravenous midazolam and disoprivan. Prophylactic antibiotics were administered prior to the procedure (ceftriaxone is preferred). The common bile duct was visualized using a linear echoendoscope with color Doppler assessment for regional vasculature. Common bile duct puncture was performed using a 19-gauge needle. The puncture site was chosen after careful endosonographic assessment of the biliary tree and the anatomy of the periduodenal region, especially the neighboring vessels. The guiding principle for antegrade choledochoduodenostomy is that the wire exiting from the needle should be directed toward the hilum of the liver. Once a puncture was made, confirmation of biliary access was achieved by bile aspiration through the needle and contrast instillation under fluoroscopy. Subsequently, a 0.0035 in. guidewire was inserted through the needle and directed upstream into the bile ducts of the liver. The needle was withdrawn, and a wire-guided high-frequency ring knife (MTW-Endoskopie) was inserted. Under changing EUS and fluoroscopy control, the motion of the ring knife during high-frequency cauterization was followed. This maneuver should be done two or three times depending on the length and the resistance of the intermediate tissue. When the ring knife without cauterization passes the bile duct without problems or a spontaneous bile flow is seen, the stenting can be done. When problems occur in this maneuver because of distance to the bile duct or high resistance on the ring knife, a balloon dilatation is preferred with a 4 or 6 mm
http://dx.doi.org/10.1016/S2212-0971(13)70209-7
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MaxForce Balloon (Boston Scientific) to create a bigger choledochoduodenal fistula. A commercially available covered metal stent, 6 cm or 8 cm with an 8F deployment system and an olive tip (Boston Scientific), was placed under echoendoscopic and fluoroscopic view. The position of the stent in the duodenum should be 1.5–2 cm in the lumen to avoid stent dislocation. In some cases the application of hemoclips to the stent near the mucosa prevents dislocation of the stent. On the first postinterventional day the stent position and function is controlled using transabdominal ultrasound. EUS-guided choledochoduodenostomy (EUS-CD) is a relatively novel technique that allows biliary duct drainage with a success rate of nearly 80–95% in a very select patient subset in which this cannot be accomplished by ERCP.5–7 It has matured over the past decade and is nowadays increasingly replacing percutaneous cholangiography in the palliation of malignant obstructive jaundice after failed ERCP. High expectations are placed on the development of newer devices that may potentially simplify EUS-CD in the future. EUS-CD has a significant learning curve, failure, and complication rates. However, EUS-CD is expected to grow in clinical practice with the increasing availability of trained operators in both EUS and ERCP.2,4,6,7
Key Learning Points/Tips and Tricks
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EUS-CD is a possible technique for internal drainage in patients with malignant jaundice for palliative care to prevent external drainage via PTCD if endoscopic retrograde cholangiography is unsuccessful. The antegrade extrahepatic drainage with EUS-CD still requires the finding of the common bile duct from the duodenal bulb or the antrum of the stomach. Puncture using a 19G needle is the first step, followed by creation of a fistula with a ring knife or balloon to insert a plastic or covered metal stent self expanded metallstent (SEM). The use of a ring knife may be technically easier than graded dilation, because the ring knife burns itself into the bile duct and makes the subsequent passage of the stent delivery system easier. The advantage of covered SEM is sealing the dilation tract, which prevents biliary leakage; also, the large diameter is preferable for a long-term patency and an easy reintervention if the stent is obstructed. The serious risk of stent dislocation by foreshortening of the SEM and subsequent bile peritonitis should be prevented with careful attention, and in difficult cases the application of metal clips.
Scripted Voiceover Time (min:sec)
Voiceover text
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Again, endoscopic ultrasound (EUS)-guided choledochoduodenostomy is considered an advanced technique of interventional endoscopy
for internal drainage of bile in patients with malignant jaundice and where endoscopic retrograde cholangiopancreatography (ERCP) is impossible to perform. 00:10–00:28
In a patient with jaundice, following palliative gastroenterostomy due to an irresectable tumor in the head of the pancreas with duodenal stenosis, transabdominal ultrasound reveals dilated intrahepatic branches of the biliary system and common bile duct. The papilla is not detectable with an endoscope in the tumor lesion.
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Endosonography from the duodenal bulb shows the dilated common bile duct with intraluminal echorich sludge. Note the neighboring hepatic artery and portal vein. The fundamental issue for planning the EUS-guided choledochoduodenostomy is first searching for the safest site for an interventional approach to access the biliary system.
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The transduodenal puncture of the common bile duct through the peritoneal cavity is performed with a 19-Gauge needle.
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Using contrast media, control fluoroscopy confirms the dilated bile ducts and absent bile drainage through the papilla into the duodenum.
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Under EUS and fluoroscopy guidance, a 0.035inch guidewire is inserted through the needle into a bile duct. The guidewire should be introduced as far as possible into the intrahepatic branches of the biliary system.
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Over the guidewire, a high-frequency ring knife is pushed forward up to the duodenal wall.
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Under changing EUS and fluoroscopy control, the motion of the ring knife during high-frequency cauterization is followed carefully.
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This maneuvre should be done two or three times depending on the distance and the resistance of the intermediate tissue. When the ring knife, without cauterization, reaches the bile duct without any problems or spontaneous bile drainage out of the puncture of the duodenal site is seen, the next procedural step can be done.
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The stent delivery system, armed with a fully covered metal stent, is pushed over the guidewire. The delivery starts if the stent is positioned near the bifurcation of the biliary system.
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Here, you see endoscopic control during stent delivery. The favorable position of the intraduodenal part of the stent should be nearly 1.5 to 2 cm within the duodenal cavity. The sequences show that the intraduodenal stent part is directed through the pylorus into the gastric cavity
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Further control fluoroscopy shows the correct stent position. In addition, effusion of contrast media into the stomach can be seen.
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On the first postinterventional day, stent position is controlled using transabdominal ultrasound. The intrahepatic bile ducts show normal caliber
Endoscopic Ultrasound-Guided Choledochoduodenostomy (EUCD)
with aerobilia. The stent itself crosses the duodenum and pylorus and the distal end can be seen within the stomach. The intervention was performed with periinterventional prophylaxis using the antibiotic ceftriaxone.
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3. Ramirez-Luna, M. A.; Tellez-Avila, F. L.; Giovannini, M.; et al. Endoscopic Ultrasound-Guided Biliodigestive Drainage is a Good Alternative in Patients with Unresectable Cancer. Endoscopy 2011, 43, 826–830. 4. Maranki, J.; Hernandez, A. J.; Arslan, B.; et al. Interventional Endoscopic Ultrasound-Guided Cholangiography: Long-Term Experience of an Emerging Alternative to Percutaneous Transhepatic Cholangiography. Endoscopy 2009, 41(6), 532–538. 5. Park do, H.; Jang, J. W.; Lee, S. S.; et al. EUS-Guided Biliary Drainage with Transluminal Stenting After Failed ERCP: Predictors of Adverse Events and Long-Term Results. Gastrointest. Endosc. 2011, 74(6), 1276–1284. 6. Shah, J. N.; Marson, F.; Weilert, F.; et al. Single-Operator, Single-Session EUSGuided Anterograde Cholangiopancreatography in Failed ERCP or Inaccessible Papilla. Gastrointest. Endosc. 2012, 75(1), 56–64. 7. Perez-Miranda, M.; de la Serna, C.; Diez-Redondo, P.; Vila, J. J. Endosonography-Guided Cholangiopancreatography as a Salvage Drainage Procedure for Obstructed Biliary and Pancreatic Ducts. World J. Gastrointest. Endosc. 2010, 2(6), 212–222.
