Interventional EUS-guided cholangiography: evaluation of a technique in evolution

BackgroundInterventional EUS-guided cholangiography (IEUC) has been increasingly used as an alternative to percutaneous transhepatic cholangiography (PTC) in cases of biliary obstruction when ERCP is unsuccessful.ObjectiveWe reviewed our experience and technique used for this procedure.DesignOver a 3-year period, ending July 2005, patients with a failed ERCP were offered an IEUC.SettingTertiary care center offering ERCP and interventional EUS.PatientsTwenty-eight patients were candidates for IEUC. Two patients had bleeding masses and were referred to interventional radiology, 1 patient had a large mass occupying the duodenal lumen, and 2 patients refused IEUC.InterventionEUS was used to access the biliary system after which a guidewire was advanced antegrade across the obstruction. Either rendezvous with retrograde or antegrade drainage was then accomplished.Main Outcome MeasurementsEfficacy and safety of IEUC for biliary decompression.ResultsIEUC was successfully performed in 23 patients, with a transgastric-transhepatic (intrahepatic) approach in 13 cases and transenteric-transcholedochal (extrahepatic) approach in 10 cases. Therapeutic benefit was achieved in 21 patients: 18 underwent successful stent deployment across the stricture, whereas 3 patients required a choledochoenteric fistula formation. Complications included 1 case of bile leak, 2 cases of self-limited pneumoperitoneum, and 1 case of minor bleeding.LimitationsSingle-center experience of 2 operators.ConclusionsIEUC appears efficacious in patients in whom ERCP is unsuccessful and is evolving as an attractive alternative to PTC. Intrahepatic access to the biliary system appears safer than the extrahepatic approach.