Comparison of endosonography-guided vs. Percutaneous biliary stenting when papilla is inaccessible for ERCP

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting fails in 5–10% patients of malignant biliary obstruction because papilla is inaccessible. Percutaneous transhepatic biliary drainage (PTBD) is an accepted alternative. Endosonography-guided biliary drainage (EUS-BD) has been described recently. Aim: To compare success rates and complications of EUS-BD and PTBD internal stenting. Methods: This retrospective study included failed ERCP in inoperable malignant biliary obstruction due to inaccessible papilla undergoing PTBD or EUS-BD. Percutaneous transhepatic cholangiography guided/EUS-guided rendezvous procedures were excluded. When PTBD internal stenting failed, external drainage was performed. EUS-BD was performed using either intra- or extrahepatic approach, and stents were placed by transmural (choledocho-duodenostomy or hepaticogastrostomy) or antegrade approach. Self-expandable metallic stents or plastic stents were placed in both groups. Success of internal stenting and complications were compared using t-test and chi-squared test. Results: Retrospective review of 6 years of records (2005–2011) revealed 50 patients meeting the required criteria. EUS-BD was attempted in 25 and PTBD in 26 patients (one crossover from EUS-BD to PTBD). Internal stenting was technically and clinically successful in 23/25 (92%) EUS-BD vs. 12/26 (46%) PTBD (p<0.05). External catheter drainage was performed in remaining 14 PTBD patients. Complications occurred in 5/25 (20%) EUS-BD (one major, four minor) and in 12/26 (46%) PTBD (four major, eight minor; p<0.05). Late stent occlusion occurred in one EUS-BD and three PTBD. Conclusions: In this retrospective study comparing success and complications of EUS-BD and PTBD in patients with inoperable malignant biliary obstruction and inaccessible papilla, EUS-BD was found superior to PTBD for both comparators.