[Endoscopic ultrasonography (EUS)-guided transluminal cholangiodrainage (EUCD) - a novel option of interventional endoscopy in the interdiciplinary management of obstructive jaundice]

U Will, F Meyer
Zentralblatt Für Chirurgie 2012, 137 (1): 20-31

BACKGROUND: ERCP and PTCD are considered the gold standard in the interventional treatment of biliary obstruction, in particular, with palliative intention. If ERCP and PTCD are not possible, an alternative drainage procedure such as the EUS-guided cholangiodrainage (EUCD) can be used. AIM / METHOD: By the mean of a compact review, indication, technique, variants of approach, number of treated patients and therapeutic procedures reported by various authors, success rate, spectrum and management of complications as well as recommendations for an appropriate follow-up-investigation protocol for EUCD based on our own clinical experiences and compared to published data are described.

RESULTS: EUCD is an interventionally endoscopic / -sonografic procedure, which is used in case of postoperatively changed anatomy of the upper GI tract (BII gastric resection, PPPHR, Whipple procedure, [sub-]total gastrectomy, Roux-en-Y reconstruction) and, thus, if papilla of Vater (papilla) can not be reached or catheterized or if the patient denies PTCD in subjects with recurrent, advanced or metastasized tumor lesion(s) of the upper abdomen, hepatobiliary system as well as pancreas and associated obstruction of the biliary tree - / + jaundice.

PRINCIPLE: EUS-guided transluminal puncture from the upper GI tract into various extra- / intrahepatic segments of the biliary system, recanalization of the tumor stenosis with stent insertion through the access site or bypassing the tumor (stent-based retro- or antegrade drainage of the biliary tree). Derived from this, there are various approaches and procedures - EUCD i) combined with rendesvouz technique, ii / iii) transhepatically with retro- (permanent hepaticoenterostomy) / antegrade internal drainage, iv) extrahepatically with antegrade drainage (permanent choledocho-enterostomy), which are distinguished according to tumor site, possible direction of translumenal puncture, insertion of a guide wire and final stent placement. Within the spectrum of complications (rateLit.: 0 - 25 %), bleeding, perforation, stent dislocation / -migration/-occlusion and slight postinterventional pain are relevant. Currently, approximately 200 cases have been published worldwide; the clinical experience of the reporting institution is based on more than > 70 interventions.

DISCUSSION: With regard to the limited diffusion process, EUCD cannot be considered a standard procedure yet. The advantages comprise low tissue trauma, primary internal drainage and the possible endoscopic re-intervention in case of complications. The high technical challenge in performing EUCD is a disfavourable aspect for broader use in clinical practice. However, the disclosed treatment results demonstrating an acceptable complication rate show that EUCD can be competitively considered to ERCP und PTCD with a great chance for primary success.

CONCLUSION: EUCD is an elegant, not yet fully established, but rather still experimental procedure of interventional endoscopy / EUS, which needs great expertise of the endoscopist in an interdisciplinary centre of visceral medicine as one of the main predictions. In experienced hands, a safe procedure can be provided, for which a systematic follow-up and a multicentre evaluation of periinterventional management are still needed in order to achieve a final assessment of EUCD for guideline approval.

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