ERCP failure: EUS gallbladder drainage as first alternative?

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is gaining popularity as an option for drainage of the gallbladder in patients suffering from acute cholecystitis who are at high risk for cholecystectomy [1]. The procedure could also be used to convert permanent cholecystostomy to internal drainage [2]. EUS-GBD has been shown by multiple retrospective studies to be associated with reduced adverse events (AEs), reinterventions and readmissions [3 – 5]. The advent of a cautery-tipped lumen-apposing stent also significantly reduced the complexity of the procedure and allowed for creation of a secure anastomosis [6 – 7]. In this issue of Endoscopy International Open, Chang et al presented a series of nine patients who received EUS-GBD as a method of drainage in malignant biliary obstruction with failed ERCP [8]. They reported a clinical success rate of 77.78 %. One patient suffered from recurrent obstruction at 7 months after EUS-GBD and received EUS-guided choledochoduodenostomy.

Performance of EUS-GBD in the setting of malignant biliary obstruction (MBO) is similar to the principle of surgical cholecystojejunostomy. In the 1980 s and 1990 s, there was extensive debate in the surgical literature about whether cholecystojejunostomy or hepaticojejunostomy provided better palliation of MBO. There are several concerns about using the gallbladder as a conduit for biliary drainage. First, effectiveness of the biliary drainage depends on the patency of the cystic duct. In a retrospective study assessing incidence of patent cystic ducts on cholangiograms performed by endoscopic retrograde cholangiopancreatography (ERCP) in patients with MBO, only 50 % of patients had a patent hepatocystic junction [9]. Furthermore, two-thirds of the remaining patients had obstructions less than 1 cm from the hepatocystic junction, potentially increasing risk of future cystic duct obstruction. Results from multiple surgical series demonstrated that the overall rate of recurrent biliary obstruction was between 8 % and 48 % [10 – 12]. Thus, proximity of the cystic duct opening to the site of obstruction may be a risk factor for recurrent obstruction.

EUS-guided biliary drainage (EUS-BD) can be achieved by a number of approaches, either transpapillary or transmurally [13 – 14]. For transpapillary approaches, EUS-rendezvous ERCP or antegrade stenting could be performed. For transmural procedures, EUS-guided choledochoduodenostomy (CDS) and hepaticogastrostomy (HGS) could be performed. Performance of these procedures during the learning curve can be associated with a risk of AEs. Performance of them by an endoscopist fluent in them is associated with procedural AE rates comparable to that of ERCP. The availability of single-step devices for CDS and hepaticogastrostomy will further improve the ease and safety of performing these procedures [15 – 16]. The benefit of transmural drainage is that the stent is placed in the bile duct far from the tumor, thus risk of tumor in-growth is significantly reduced. Indeed, a recent randomized study demonstrated that EUS-BD may provide higher stent patency rates and lower AE rates (particularly for pancreatitis) as compared to ERCP in unresectable MBO [16].

Hence, in the presence of available expertise and devices, EUS-BD should still be the first choice for draining MBO. In the event that EUS-BD cannot be performed, EUS-GBD can then potentially provide another option for biliary drainage.