EUS-guided antegrade intervention for benign biliary diseases in patients with surgically altered anatomy (with videos).Mukai S, Itoi T, Sofuni A, Tsuchiya T, Tanaka R, Tonozuka R, Honjo M, Fujita M, Yamamoto K, Nagakawa Y. Gastrointest Endosc. 2018 Aug 1. [Epub ahead of print]

BACKGROUND AND AIMS: Although balloon enteroscopy-assisted ERCP (BE-ERCP) is effective and safe for benign biliary diseases in patients with surgically altered anatomy (SAA), BE-ERCP is not always successful. Recently, EUS-guided antegrade intervention (EUS-AI) including a 1-stage or 2-stage procedure has been developed for BE-ERCP failure cases.

The aim of the present study was to evaluate the outcome of EUS-AI for benign biliary diseases with SAA.METHODS: Of 48 patients in whom BE-ERCP failed, percutaneous transhepatic intervention was performed in 11 patients. Another 37 patients who failed BE-ERCP and underwent EUS-AI for benign biliary diseases with SAA [common bile duct stones (n = 11), intrahepatic bile duct stones (n = 5), anastomotic stricture (n = 21)] from November 2013 until November 2017 were retrospectively reviewed.RESULTS: The overall technical success of the creation of hepaticoenteric tract by EUS was 91.9% (34/37). Moderate adverse events were observed in 8.1% (biliary peritonitis [n=3]). One-stage EUS-AI by EUS succeeded in 8 cases (100%) without any adverse events. In another 26 cases, 2-stage EUS-AI by ERCP was performed about 1 or 2 months later. Endoscopic antegrade therapy under fluoroscopy was successful in 6 cases. Per-oral cholangioscopy-assisted antegrade intervention were required in 19 cases (guidewire manipulation across the anastomotic stricture [n=6], cholangioscopy-guided lithotripsy using electrohydraulic lithotripsy [n=13]). In 1 case, magnetic compression anastomosis was performed. The final clinical success rate of all EUS-AI was 91.9%.CONCLUSIONS: EUS-AI for benign biliary diseases with SAA appears to be a feasible and safe alternative procedure after BE-ERCP failure.

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