RESUMEN

PURPOSE: Bile duct stenting during ERCP has long been established as the gold standard for the treatment of biliary obstruction. However, when the ampulla cannot be reached or bile duct cannulation fails, percutaneous or surgical drainage is performed. The study aimed to investigate the feasibility and long-term outcome of a potential alternative intervention, EUS-guided transluminal biliary drainage (EUBD), in a representative number of patients. MATERIALS AND METHODS: All patients undergoing EUBD were included in a prospectively collected single-center database over a 10-year period. Feasibility was characterized by technical and clinical success, including long-term follow-up data. RESULTS: From IV/2002 - XI/2012, 10 832 EUS and 8756 ERCP procedures were performed. Simultaneously, 223 PTCD and 95 EUBD were performed. Cholangiography was achieved in 93/95 patients (97.9 %). However, in one patient stone extraction was executed by means of the rendezvous technique. Therefore, drainage was not necessary. Intention to treat with EUS-guided drainage was given in 80/94 patients (86.9 %) using different techniques depending on anatomical variations and requirements. The cause of bile duct obstruction could not be cured in 77 patients (malignancy). In 18 patients, a benign (n = 15) or unknown etiology (n = 3) of bile duct stenosis was found. The complication rate was 15.7 % (mortality, 1.1 %; n = 1/95). The follow-up ranged from 3 - 60 months with reintervention in 3 patients. CONCLUSION: EUBD is a promising therapy for bile duct obstruction in patients predominantly with malignant diseases. Using EUBD, an excellent interventional approach is available for long-term internal drainage to prevent percutaneous drainage (PTCD). EUS-guided drainage is challenging and needs extraordinary interventional expertise, preferentially in tertiary gastroenterological and endoscopic centers.

Asunto(s)

Cateterismo/métodos , Colestasis/diagnóstico por imagen , Colestasis/terapia , Drenaje/métodos , Ultrasonografía Intervencional/métodos , Adulto , Anciano , Anciano de 80 o más Años , Colangiografía , Colestasis/etiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Stents , Resultado del Tratamiento

RESUMEN

PURPOSE: The study aim was to investigate the diagnostic value of US-guided percutaneous needle biopsy in the case of suspicious tumor lesion of the GI tract revealed by abdominal US but without detection with endoscopy or with incomplete or no possible endoscopy. PATIENTS AND METHODS: Over a defined time period, all consecutive patients with no appropriate endoscopic diagnostic specimen or finding were registered. The patient, diagnostic, and periinterventional characteristics were documented. RESULTS: In total, 16 patients (7 males; mean age, 63.2 [range, 43 - 90] years) were enrolled in this study representing a rare but possible constellation from endoscopic practice characterized by no detectable intraluminal tumor growth and a suspicious tumor lesion revealed with abdominal US as found in each case (n = 16) from 01 / 01 / 2003 - 12 / 31 / 2006. The main indications for needle biopsy were pathological colonic cockades (n = 7) and tumor lesions of the stomach and small intestine (n = 9). The first needle biopsy attempt was successful in all subjects (technical success rate: 100 %) using the color-coded US mode in each case (100 %). There were no postinterventional complications (rate: 0 %). CONCLUSION: Percutaneous US-guided needle biopsy can be considered a safe diagnostic tool for clarifying the differential diagnosis of suspicious tumor lesions of the GI tract (revealed originally only by abdominal US) as the next favorable diagnostic step in the rare situation that endoscopy cannot provide appropriate information, in order to shorten the diagnostic course, to achieve a therapeutic decision and to decrease effort and costs.

Asunto(s)

Biopsia con Aguja/métodos , Endoscopía Gastrointestinal , Neoplasias Gastrointestinales/diagnóstico por imagen , Neoplasias Gastrointestinales/patología , Ultrasonografía Intervencional/métodos , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias del Colon/diagnóstico por imagen , Neoplasias del Colon/patología , Diagnóstico Diferencial , Femenino , Humanos , Neoplasias Intestinales/diagnóstico por imagen , Neoplasias Intestinales/patología , Intestino Delgado/diagnóstico por imagen , Intestino Delgado/patología , Masculino , Persona de Mediana Edad , Sensibilidad y Especificidad , Neoplasias Gástricas/diagnóstico por imagen , Neoplasias Gástricas/patología

RESUMEN

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP)-guided implantation of a biliary endoprosthesis or stent is the gold standard treatment for biliary obstructions. When the papilla cannot be traversed because there is pyloric or duodenal stenosis, or the catheter cannot be introduced, or because of previous gastrointestinal surgery (Billroth II gastric resection, Whipple procedure, gastrectomy with Roux-en-Y reconstruction), the alternative treatment is considered to be percutaneous transhepatic cholangiography and drainage (PTCD). The aim of the study was to investigate the further alternative of endoscopic ultrasound (EUS)-guided transgastric or transjejunal biliary drainage where PTCD failed or was declined, and particularly, the feasibility and outcome of this option. PATIENTS AND METHODS: Over 3 years all appropriate consecutive patients (as defined above) were enrolled in this prospective, observational, single-center, case series study, and patient and intervention data were recorded. Feasibility was characterized by success rate (regression of cholestasis), and outcomes by complication rate, mortality, and follow-up findings. RESULTS: Between November 2002 and December 2005, eight patients (in 10 interventions) underwent this new biliary drainage procedure. The routes were transesophageal (n = 1), transgastric (n = 4), and transjejunal (n = 3, including a rendezvous technique with ERCP [n = 1]). The indications were cholestasis, arising from recurrent tumor growth (n = 5, 62.5%), that included gastric carcinoma after previous gastrectomy (n = 4) and a periampullary carcinoma after previous Whipple procedure (n = 1); arising from Klatskin tumor (n = 2, 25%); and from benign stenosis of a hepaticojejunostomy (n = 1, 12.5%). Five patients (62.5%) received a metal stent, and three (37.5%) had a plastic prosthesis (8.5-Fr double-pigtail). The technical success rate was 90% (9/10) and the clinical success rate was 88.9% (8/9). There was only one case of cholangitis (12.5%) and slight postinterventional pain, but no severe complications such as bleeding or perforation, and no mortality. During follow-up (range 4 weeks to 3 years) re-interventions were needed in two patients (20%) because of increasing cholestasis; these resulted in technical success and clinical improvement. CONCLUSION: EUS-guided transgastric or transjejunal biliary drainage is a reasonable, feasible and encouraging treatment option in selected patients as indicated, with a low peri-interventional risk. It broadens the therapeutic spectrum but still needs further evaluation and follow-up investigation.

Asunto(s)

Colestasis/cirugía , Drenaje/métodos , Endosonografía , Femenino , Gastroscopía , Humanos , Masculino , Conductos Pancreáticos/diagnóstico por imagen , Estudios Prospectivos