Durability and outcome of EUS-guided hepaticoduodenostomy using a fully covered metal stent for segregated right intrahepatic duct dilatation.

BACKGROUND/AIMS: segregated right intrahepatic duct dilatation (IHD) results from complete obstruction of the biliary tract proximal to the hilar level. We aimed to evaluate long-term efficacy and safety of EUS-HDS in segregated right IHD.

METHODS: Consecutive patients who had undergone EUS-guided HDS with a fully covered self-expandable metal stent (FCSEMS) in an academic tertiary center were recruited. All patients had segregated right hepatic duct and failed drainage by ERCP. Demographic data, endoscopic findings, procedure details and outcome data were extracted from a prospectively maintained database.

RESULTS: From 2013 to 2017, there were 35 patients who had undergone EUS-guided HDS with a median follow-up duration of 169 (3-2091) days. Malignancy accounted for 71.4% of the ductal segregation, followed by surgical complication (17.1%). Technical and clinical success rate was 97.1% and 80% respectively. Early adverse event (AE) happened in 7 patients (20%), two of them required endoscopic re-intervention, no PTBD or surgery was performed because of AE. The median stent patency duration was 331 (3-1202) days. The median duration of fistula tract keeping was 1280 (3-1280) days. There was no significant difference in terms of patency rate with respect to whether the underlying pathology was benign or malignant (P=0.776). EUS-guided HDS for right posterior sectional duct (RPSD) segregation was associated with higher 3-month stent patency rate when compared to right anterior sectional duct (RASD) (79.1% vs 38.1%, P=0.012).

CONCLUSION: EUS-guided HDS with an FCSEMS appears to be a safe and effective treatment as a viable alternative option to PTBD after failed ERCP. It creates a durable and reliable fistula tract for permanent access to an isolated ductal system and this application deserves more attention.