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Endoscopic ultrasonography guided biliary drainage: Summary of consortium meeting, May 7th, 2011, Chicago  [cached]
Michel Kahaleh,Everson LA Artifon,Manuel Perez-Miranda,Kapil Gupta
World Journal of Gastroenterology , 2013, DOI: 10.3748/wjg.v19.i9.1372
Abstract: Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7th, 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting’s agenda and the conclusions generated by the creation of this consortium group.
Endoscopic ultrasound-guided biliary drainage
Disaya Chavalitdhamrong,Peter V Draganov
World Journal of Gastroenterology , 2012, DOI: 10.3748/wjg.v18.i6.491
Abstract: Endoscopic ultrasound (EUS)-guided biliary drainage has emerged as a minimally invasive alternative to percutaneous and surgical interventions for patients with biliary obstruction who had failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-guided biliary drainage has become feasible due to the development of large channel curvilinear therapeutic echo-endoscopes and the use of real-time ultrasound and fluoroscopy imaging in addition to standard ERCP devices and techniques. EUS-guided biliary drainage is an attractive option because of its minimally invasive, single step procedure which provides internal biliary decompression. Multiple investigators have reported high success and low complication rates. Unfortunately, high quality prospective data are still lacking. We provide detailed review of the use of EUS for biliary drainage from the perspective of practicing endoscopists with specific focus on the technical aspects of the procedure.
Directable Needle Guide: Efficacy for Image-Guided Percutaneous Interventions  [PDF]
Hiroshi Ishizaka
ISRN Radiology , 2013, DOI: 10.5402/2013/516941
Abstract: Diagnostic and therapeutic image-guided percutaneous interventions have become increasingly important in the clinical management of various conditions. Though precise needle placement via a safe route is essential for successful percutaneous interventions, it is often difficult in cases of deeply situated, small lesions. The present paper describes the efficacy of the directable needle guide (DNG), which allows manipulation of the direction of a fine needle within organs. The DNG was used in patients for needle biopsy of hepatic ( ) and splenic ( ) lesions and for percutaneous ethanol injection therapy for liver tumors ( ) under sonographic or computed tomography guidance. The DNG enabled the direction of a 21- or 22-gauge needle to be successfully changed during needle advancement in all cases, allowing adjustment of the location of the needle tip or needle access root to avoid vessels, the gallbladder, and the lungs. We conclude that DNG increases the safety and ease of percutaneous interventions. 1. Introduction Image-guided percutaneous interventions with a fine needle are used for various clinical purposes, including biopsies, antitumor therapy with ethanol injection, laser thermal ablation, gene-technology implants, and nerve blocks [1–4]. Though precise needle placement passing through a safe root is essential for percutaneous interventions, it is often difficult due to needle deflection and patients’ respiratory or postural variations during the procedure and also because of intervening vital structures on the root. When a thin beveled needle is inserted into any organ, the tip of the needle has a tendency to curve toward the side when advancing, due to its flexibility. However, when a beveled needle is inserted with a twisting motion, it advances in a straight path. This phenomenon was applied to create a directable needle guide (DNG) that could be used to steer a needle within organs. The present paper describes the utility of the DNG in our clinical experience. 2. Subjects and Methods The DNG was used in patients undergoing both needle biopsy of hepatic ( ) or splenic ( ) lesions and percutaneous ethanol injection therapy for liver tumors ( ). Sonography and computed tomography (CT) images were used for imaging guidance in 43 and 17 lesions, respectively. The DNG (0.018 inches in diameter; 250?mm long) with a flattened segment (0.010 inches in thickness) on the distal portion of the beveled side of the tip (Leadway, Hakko, Tokyo, Japan, a prototype not commercially available at present) (Figures 1(a) and 1(b)) was used to direct the needle
Diagnosis of Cancer Spread Using Percutaneous Transhepatic Biliary Cholangioscopy-guided Ultrasonography for Malignant Bile Duct Stenosis  [PDF]
Hirokazu Inoue
Diagnostic and Therapeutic Endoscopy , 2001, DOI: 10.1155/dte.7.159
Abstract: The characteristics of sites of intramural cancer spread were examined by comparing the intraductal ultrasonography (IDUS) and wall thickening findings at sites of intramural cancer spread and non-spread, in patients with malignant bile duct stenosis who had undergone percutaneous transhepatic biliary drainage (PTBD).
Endoscopic ultrasound guided biliary drainage
Ilaria Tarantino,Luca Barresi,Carlo Fabbri,Mario Traina
World Journal of Gastrointestinal Endoscopy , 2012, DOI: 10.4253/wjge.v4.i7.306
Abstract: Endoscopic retrograde cholangio-pancreatography (ERCP) is the most appropriate technique for treating common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Even if the procedure is performed by skillful endoscopist, there are patients in whom endoscopic stent placement is not possible. Common causes of failure include complex peri-papillary diverticula, prior surgery procedures, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones. Percutaneous trans-hepatic biliary drainage (PTBD) and surgical intervention carry morbidity and mortality. Recently endoscopic ultrasonography-guided biliary drainage has been reported as an alternative technique. Endoscopic ultrasonography-guided biliary drainage (EUS-BD) using either direct access or a rendezvous technique has attracted attention as an alternative procedure to PTBD, with a technical success between 75%-100% and with low complication rate. We have reviewed published data on EUS guided biliary drainage procedures with the aim of summarizing the efficacy and safety of this promising method.
A severe case of hemobilia and biliary fistula following an open urgent cholecystectomy
Vincenzo Napolitano, Roberto Cirocchi, Alessandro Spizzirri, Lorenzo Cattorini, Francesco La Mura, Eriberto Farinella, Umberto Morelli, Carla Migliaccio, Pamela Del monaco, Stefano Trastulli, Micol Di Patrizi, Diego Milani, Francesco Sciannameo
World Journal of Emergency Surgery , 2009, DOI: 10.1186/1749-7922-4-37
Abstract: We report here a case of massive hemobilia in a 60-year-old man who underwent an urgent open cholecystectomy and a subsequent placement of a transhepatic biliary drainage.The management of these complications enclose endoscopic, percutaneous and surgical therapies. After a diagnosis of biliary fistula, it's most important to assess the adequacy of bile drainage to determine a controlled fistula and to avoid bile collection and peritonitis. Transarterial embolization is the first line of intervention to stop hemobilia while surgical intervention should be considered if embolization fails or is contraindicated.Percutaneous transhepatic biliary drainage (PTHBD) is one of the most therapeutic options for the menagement of biliary obstructive disorders, but the use of interventional procedures is associated with an increased incidence of arteriovenous shunting, hepatic artery pseudoaneurysm and vascular stenoses that result in hemobilia[1].The diagnosis of hemobilia may be difficult because of a variety of clinical manifestations and sometimes can be fatal. Its management aims to stopping the bleeding and resolve obstruction. Actually the development of interventional radiology, such as transarterial embolization, has been recognized the first line of procedure to stop hemobilia with a success rate of about 80%-100%, by ensuring that the classic surgery interventions, such as ligation of bleeding vessels or excisions of aneurysms, should be considered fails and burdened by high mortality [2,3].A 60-year-old man came to our observation with intermittent pain localized to upper quadrants of the abdomen, fever (39°C) preceded by thrill, vomiting and signs of peritoneal interesting. Laboratory tests revealed leucocytosis (18300 WBC), and the increment of cholestasis markers, while US scan demonstred an acute cholecystitis with lithiasis, without biliary tree dilatation, and a small liquid flap next to gallbladder.Because of poor conditions, we decided to perform a surgical o
EUS-Guided Biliary Drainage
Marc Giovannini,Erwan Bories
Gastroenterology Research and Practice , 2012, DOI: 10.1155/2012/348719
Abstract: The echoendoscopic biliary drainage is an option to treat obstructive jaundices when ERCP drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear setorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimenion on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonographic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampulary diverticula, and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Dilatation is required before stent introduction, and a plastic or metallic stent is introduced. This phrase should be replaced by: diathermic dilatation of the puncturing tract is required using a 6F cystostome. The technical success of hepaticogastrostomy is near 98%, and complications are present in 36%: pneumoperitoneum, choleperitoneum, infection, and stent disfunction. To prevent bile leakage, we have used the 2 stent techniques, the first stent introduced was a long uncovered metallic stent (8 or 10 cm), and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92% and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 19%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution.
Malfunctioning Plastic Biliary Endoprosthesis: Percutaneous Transhepatic Balloon Pulling Technique  [PDF]
Umberto G. Rossi,Paolo Rigamonti,Maurizio Cariati
Case Reports in Radiology , 2013, DOI: 10.1155/2013/596480
Abstract: Percutaneous transhepatic removal techniques for malfunctioning plastic biliary endoprosthesis are considered safe and efficient second-line strategies, when endoscopic procedures are not feasible. We describe the percutaneous transhepatic balloon pulling technique in a patient with an unresectable malignant hilar cholangiocarcinoma. 1. Introduction Plastic biliary endoprosthesis is successfully implanted as a minimally invasive palliative treatment in the management of malignant biliary obstruction [1–3]. Occlusion and/or migration of the plastic biliary endoprosthesis for tumour growth is a challenging procedure for gastroenterologist and interventional radiologist in removing the occluded and/or displaced endoprosthesis [1]. We present a case of occluded and proximal migrated plastic biliary endoprosthesis that was percutaneously removed by balloon catheter pulling technique. 2. Case Description A 71-year-old female patient with an unresectable malignant hilar cholangiocarcinoma (Klatskin tumor) associated with a direct bilirubin level of 22?mg/dL and dilation of intrahepatic biliary ducts (Figure 1(a)) underwent palliative percutaneous bilateral external biliary drainage. After 5 days, the two external biliary drainages were replaced by two plastic biliary endoprostheses 12-Fr (Boston Scientific, Natick, MA), as a palliative treatment (Figure 1(b)). Three months later, she was evaluated for a mild dilatation of left intrahepatic biliary ducts and left percutaneous access biliary leak. The left biliary endoprosthesis appeared occluded at its proximal third and proximally migrated due to tumour growth (Figure 2(a)). Due to the proximal displacement of the left biliary endoprosthesis and the presence of the biliary leak, we decided to accede it percutaneously. After removing the left subcutaneous fixing ring, from the left percutaneous previous access (through the percutaneous biliary leak), we have passed a guide wire through the endoprosthesis from the proximal tip to first lateral hole because the endoprosthesis was occluded further this hole. An 8?Fr diameter introducer sheath (Terumo, Tokyo, Japan) was positioned. After multiple attempts of endoprosthesis removal by pushing it with the dilatator of the introducer sheath and a 3.5 × 40?mm balloon catheter (Abbott, Beringen, Switzerland) that was inflated coaxially outside the proximal end of the endoprosthesis, we decide to inflate the balloon catheter partially (half of it) inside the proximal end of the endoprosthesis (Figure 2(b)) and to pull back the device through the percutaneous transhepatic
Factors relating to the short term effectiveness of percutaneous biliary drainage for hilar cholangiocarcinoma  [cached]
Hong-Ming Tsai, Chiao-Hsiung Chuang, Xi-Zhang Lin, Chiung-Yu Chen
World Journal of Gastroenterology , 2009,
Abstract: AIM: To identify factors that were related to the short term effectiveness of percutaneous transhepatic biliary drainage in cholangiocarcinoma patients and to evaluate the impact of palliative drainage on their survival.METHODS: Seventy-four patients with hilar cholangiocarcinoma who underwent percutaneous biliary drainage were enrolled in the study. The demographic and laboratory data as well as the imaging characteristics were retrospectively analyzed to correlate with the bile output and reduction rate of serum bilirubin 1 wk after drainage.RESULTS: Patients with more bile duct visualized on percutaneous transhepatic cholangiography or absence of multiple liver metastases on imaging studies had more bile output after biliary drainage [odds ratio (OR): 8.471, P = 0.010 and OR: 1.959, P = 0.022, respectively]. Patients with prolonged prothrombin time had a slow decrease in serum bilirubin (OR: 0.437, P = 0.005). The median survival time was not significantly different in patients with low or high bile output (75 d vs 125 d, P = 0.573) or in patients with slow or rapid reduction of serum bilirubin (88 d vs 94 d, P = 0.576).CONCLUSION: The short term effectiveness of percutaneous biliary drainage was related to patient’s prothrombin time or the extent of tumor involvement. It, however, had no impact on survival.
EUS-guided choledochoduodenostomy for malignant distal biliary obstruction palliation:an article review
Everson L.A. Artifon;Manuel Perez-Miranda;
Endoscopic Ultrasound (EUS) , 2012, DOI: 10.7178/eus.01.002
Abstract: The EUS-guided biliary drainage is a new tool for the palliation of distal obstructive biliary lesions. The EUS-guided access,which creates a fistulization between the duodenal bulb and distal common biliary duct, is an effective method to relievejaundice and has low morbidity and mortality, in patients with distal biliary obstruction (pancreatic mass or papillary cancer).This technique is called choledochoduodenostomy and is presented promptly in this article. The EUS-guided biliary drainageshould be made within protocol conditions and done by very experienced endosonographers.
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