Original article
Clinical endoscopy
Hepaticogastrostomy or choledochoduodenostomy for distal malignant biliary obstruction after failed ERCP: Is there any difference?

https://doi.org/10.1016/j.gie.2014.09.047Get rights and content

Background

EUS-guided biliary drainage (BD) is an evolving alternative technique for patients with malignant biliary obstruction for which ERCP failed.

Objective

To compare the outcomes of 2 nonanatomic EUS-guided BD routes: hepaticogastrostomy (HPG) and choledochoduodenostomy (CD).

Design

Prospective, randomized trial.

Setting

Tertiary endoscopic referral center.

Patients

Forty-nine patients with unresectable distal malignant biliary obstruction and failed ERCP were included. The HPG group had 25 patients and the CD group had 24 patients.

Interventions

EUS-guided HPG or CD. In all procedures, a biliary puncture with a 19-gauge needle followed by cholangiography, wire advancement, track dilation, and self-expandable metal stent deployment were performed.

Main Outcome Measurements

Technical and clinical success, quality of life, adverse events, and survival.

Results

The technical success rate was 96% for HPG and 91% for CD. The clinical success rate was 91% for HPG and 77% for CD. The mean procedural time was 47.8 minutes for HPG and 48.8 minutes for CD. The mean scores of quality of life were similar during follow-up. The overall adverse event rate was 16.3% (20% for the HPG group and 12.5% for the CD group). One patient with a bile leak required percutaneous biloma drainage. There was no statistical difference between the 2 techniques and no difference with regard to survival time between the 2 groups.

Limitations

Single-center study.

Conclusion

HPG and CD techniques are similar in efficacy and safety. Both HPG and CD seem valid alternative options for BD in patients with distal malignant biliary obstruction after failed ERCP.

Section snippets

Methods

Between April 2010 and December 2013, a total of 1759 ERCP procedures for malignant obstructive jaundice relief were performed at the Hospital das Clinicas da Universidade de Sao Paulo for treatment of the malignant biliary obstruction. All patients with unresectable distal malignant biliary obstruction undergoing ERCP consented to undergo possible EUS-guided BD in case of a failed ERCP. Before providing consent, the patients received an explanation and information about the possible drainage

Results

A total of 49 patients (24 female/25 male) were included in the study; 25 patients underwent HPG and 24 underwent CD. Patient demographic and clinical information is summarized in Table 1. The Karnofsky performance status in both groups was similar (P = .201). All patients had intra- and extrahepatic biliary dilation. In 40 patients, the papilla was not accessible and the patients were directly randomized to HPG or CD. The rendezvous maneuver was attempted in 30 patients and failed in 9

Discussion

After the first description of EUS-guided CD13 and EUS-guided HPG,14 many improvements and variations of the technique were described.15 Many retrospective studies showed that EUS-guided BD is at least as good as the current alternatives for BD in expert hands for patients with failed ERCP.16, 17, 18, 19 Recently, EUS-guided biliary technique was compared with the current standard alternatives for BD in patients in whom ERCP failed.20, 21 An international consortium of experts in therapeutic

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  • Cited by (0)

    DISCLOSURE: Dr Kahaleh has received research grants from Boston Scientific, Mauna Kea, W.L. Gore, and Xlumena and is a consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this article.

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