Background and Aims

EUS-guided hepaticoenterostomy (EUS-HE) usually is reserved for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiography (ERC) or inaccessible biliary tree in surgically altered anatomy (SAA). We describe the outcome of EUS-HE and antegrade therapy for benign biliary disease in patients with SAA.

Methods

Retrospective review of 20 consecutive patients with surgically altered anatomy and benign biliary obstruction who underwent EUS-HE performed by 1 endoscopist at a tertiary-care center over a 3-year period.

Results

During the study period, 37 patients underwent EUS-HE; 24 for benign disease. Of these, 20 patients had SAA and were analyzed (15 women, mean age, 62 years). SAA consisted of 9 Roux-en-Y gastric bypasses, 6 Roux-en-Y hepaticojejunostomy, 2 Billroth II procedures, and 3 Whipple procedures. Indications for ERC were common bile duct stones (n = 8), benign postoperative strictures (n = 7), chronic pancreatitis (n = 3), inflammatory stricture (n = 1), and treatment of a bile leak (n = 1). Five patients had previously failed balloon enteroscopy-assisted ERCs. The approach was transgastric in 15 and transjejunal in 5. In all cases, a branch of the left hepatic duct with a mean diameter of 7.8 mm was accessed. Median stent length was 80 mm, with diameters of 8 or 10 mm. Antegrade, definitive endoscopic therapy via the HE was performed in 18 patients, with an average of 2.7 procedures performed for resolution of stones and/or downstream strictures. HE stents were removed in 17 patients after a mean of 91 days without adverse events. Three patients experienced mild adverse events (1 with postprocedural pancreatitis after placement of a 10F transpapillary stent, 1 with postprocedural abdominal pain, and 1 with postprocedural cholangitis) requiring hospitalization for fewer than 3 nights; no severe adverse events occurred. The average postprocedural hospital stay was 1.3 days. No deaths occurred during follow-up.

Conclusions

EUS-HE is safe and effective in the management of benign biliary obstruction in patients with surgically altered anatomy. It creates a portal to allow definitive, antegrade therapy and is a viable alternative to other endoscopic methods in this patient population.

中文翻译：

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EUS引导的肝肠吻合术作为门户，可对解剖学改变的患者进行良性胆道疾病的明确顺行治疗

背景和目标

EUS引导的肝肠吻合术（EUS-HE）通常保留用于内镜逆行胆管造影术（ERC）失败或因手术改变的解剖结构（SAA）无法进入胆道树而恶性胆道梗阻。我们描述了EUS-HE和SAA患者良性胆道疾病的顺行治疗的结果。

方法

回顾性分析连续1例内镜医师在三级护理中心接受EUS-HE手术的20例因解剖学改变和良性胆道阻塞而手术的患者，历时3年。

结果

在研究期间，有37例患者接受了EUS-HE。24为良性疾病。在这些患者中，有20位患有SAA，并进行了分析（15位女性，平均年龄62岁）。SAA包括9个Roux-en-Y胃旁路手术，6个Roux-en-Y肝空肠吻合术，2个Billroth II手术和3个Whipple手术。ERC的指征为胆总管结石（n = 8），术后良性狭窄（n = 7），慢性胰腺炎（n = 3），炎性狭窄（n = 1）和胆漏的治疗（n = 1）。 。五例患者先前在球囊肠镜辅助下的ERC失败。该方法在15例中是经胃的，在5例中是经空肠的。在所有情况下，均进入了平均直径为7.8 mm的左肝管分支。支架的中位长度为80毫米，直径为8或10毫米。18例患者通过HE进行了完整的确定性内窥镜治疗，平均要进行2.7道手术才能解决结石和/或下游狭窄。平均91天后无不良事件的17例患者中取出HE支架。3例患者出现了轻度不良事件（1例放置10F经乳头支架置入术后发生胰腺炎，1例发生术后腹痛和1例发生术后胆管炎），需要住院少于3晚。没有发生严重的不良事件。术后平均住院时间为1.3天。随访期间未发生死亡。3例患者出现了轻度不良事件（1例放置10F经乳头支架置入术后发生胰腺炎，1例发生术后腹痛和1例发生术后胆管炎），需要住院少于3晚。没有发生严重的不良事件。术后平均住院时间为1.3天。随访期间未发生死亡。3例患者出现了轻度不良事件（1例放置10F经乳头支架置入术后发生胰腺炎，1例发生术后腹痛和1例发生术后胆管炎），需要住院少于3晚。没有发生严重的不良事件。术后平均住院时间为1.3天。随访期间未发生死亡。

结论

EUS-HE在手术解剖结构改变的患者中，对良性胆道梗阻的治疗是安全有效的。它创建了一个门户，可以进行明确的顺行治疗，并且是该患者人群中其他内窥镜检查方法的可行替代方案。