Bories E, Pesenti C, Caillol F, Lopes C, Giovannini M
Endoscopic Unit, Paoli-Calmettes Institute, Marseille, France.
Endoscopy. 2007 Apr;39(4):287-91. doi: 10.1055/s-2007-966212. Epub 2007 Mar 15.
Endoscopic retrograde cholangiopancreatography (ERCP) access to the biliary tract is sometimes impossible and percutaneous access has the disadvantages of increased morbidity and patient discomfort. We present our first results with an alternative technique: endoscopic ultrasonography (EUS)-guided transgastric biliary drainage.
11 patients (7 men, mean age 64 years) were referred for failed ERCP and biliary obstruction (malignancy n = 8, benign conditions n = 3). The retrograde approach via the papilla had been impossible due to surgical anatomy, duodenal stenosis, and hilar stricture with occlusion of the left side. EUS-guided drainage was done with endoscopic and fluoroscopic monitoring. After puncture of the left biliary duct a guide wire was inserted into it followed by tract dilation using a cystostome. A plastic or a metallic stent was placed through this gastrobiliary fistula for bile drainage.
EUS-guided left hepaticogastrostomy was successfully performed in 10/11 cases, with one failure of guide wire insertion after puncture. Plastic and covered metal stents were inserted in seven and three patients, respectively. Complications in the plastic stent group included one early occlusion requiring stent replacement, and one transient ileus. In the metallic stent group there was one bilioma and one cholangitis, due to stent shortening. Clinically, the stent was efficacious in all 10 cases; during a mean follow-up of 213 days (range 3-610), two patients presented with stent occlusion and one with stent migration, with successful endoscopic treatment in all.
EUS-guided hepaticogastrostomy is an efficient technique and could be a future alternative to percutaneous biliary drainage or palliative surgical drainage.
有时无法通过内镜逆行胰胆管造影术（ERCP）进入胆道，而经皮穿刺进入则存在发病率增加和患者不适等缺点。我们展示了一种替代技术的初步结果：内镜超声（EUS）引导下经胃胆道引流术。
11例患者（7例男性，平均年龄64岁）因ERCP失败和胆道梗阻前来就诊（恶性肿瘤8例，良性疾病3例）。由于手术解剖结构、十二指肠狭窄以及左侧肝门狭窄并闭塞，经乳头的逆行途径无法实施。EUS引导下的引流在内镜和荧光透视监测下进行。穿刺左胆管后，将导丝插入其中，随后使用造瘘器扩张通道。通过这个胃胆瘘置入塑料或金属支架以进行胆汁引流。
11例患者中有10例成功实施了EUS引导下的左肝胃造瘘术，1例穿刺后导丝插入失败。分别有7例和3例患者置入了塑料支架和覆膜金属支架。塑料支架组的并发症包括1例早期堵塞需要更换支架，以及1例短暂性肠梗阻。金属支架组出现1例胆汁瘤和1例胆管炎，原因是支架缩短。临床上，所有10例患者的支架均有效；平均随访213天（范围3 - 610天）期间，2例患者出现支架堵塞，1例出现支架移位，所有患者均经内镜治疗成功。
EUS引导下肝胃造瘘术是一种有效的技术，可能成为未来经皮胆道引流或姑息性手术引流的替代方法。
