Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California 94115, USA.
Endoscopy. 2010 Mar;42(3):232-6. doi: 10.1055/s-0029-1243858. Epub 2010 Jan 29.
Endoscopic retrograde cholangiopancreatography (ERCP) with placement of self-expandable metal stents (SEMS) for palliation of malignant obstruction may not be possible in patients with an inaccessible biliary orifice. Endoscopic ultrasound (EUS)-guided drainage methods may be useful in this setting. This study aimed to determine the outcomes of EUS-guided anterograde SEMS placement across malignant strictures in patients with an inaccessible biliary orifice. Over a 2-year period, procedural and outcomes data on all patients undergoing EUS-guided anterograde SEMS drainage after failed ERCP were prospectively entered into a database and reviewed. Five patients underwent EUS-guided anterograde SEMS. Indications included: advanced pancreatic cancer (n = 3), metastatic cancer (n = 1), and anastomotic stricture (n = 1). The biliary orifice could not be reached endoscopically due to duodenal stricture (n = 4) or inaccessible hepaticojejunostomy (n = 1). EUS-guided punctures were performed transgastrically into left intrahepatic ducts (n = 4) or transbulbar into the common bile duct (n = 1). Guide wires were passed and SEMS were successfully deployed across strictures in an anterograde fashion in all patients. Jaundice resolved and serum bilirubin levels decreased in all cases. No procedure-related complications were noted during a mean follow-up of 9.2 months. EUS-guided anterograde SEMS placement appears to be a safe and efficient technique for palliation of biliary obstruction in patients with an endoscopically inaccessible biliary orifice. The procedure can be performed at the time of failed standard ERCP, and provides an alternative drainage option to percutaneous or surgical decompression and to EUS-guided creation of bilioenteric fistulae.
经内镜逆行胰胆管造影术（ERCP）联合自膨式金属支架（SEMS）置入术可缓解恶性梗阻，但对于胆道口无法进入的患者可能无法进行。超声内镜（EUS）引导的引流方法在这种情况下可能有用。本研究旨在确定在胆道口无法进入的恶性狭窄患者中，EUS 引导的顺行 SEMS 放置术的结果。在 2 年期间，前瞻性地将所有在 ERCP 失败后接受 EUS 引导的顺行 SEMS 引流的患者的程序和结果数据输入数据库并进行了回顾。有 5 名患者接受了 EUS 引导的顺行 SEMS。适应证包括：晚期胰腺癌（n=3）、转移性癌（n=1）和吻合口狭窄（n=1）。由于十二指肠狭窄（n=4）或胆肠吻合口无法进入（n=1），内镜无法到达胆道口。EUS 引导的穿刺经胃进入左肝内胆管（n=4）或经球囊进入胆总管（n=1）。所有患者均成功地将导丝穿过并以顺行方式将 SEMS 穿过狭窄部位。所有患者的黄疸均消退，血清胆红素水平降低。在平均 9.2 个月的随访期间，未观察到与操作相关的并发症。EUS 引导的顺行 SEMS 放置术似乎是一种安全有效的技术，可缓解胆道口无法进入的患者的胆道梗阻。该操作可在标准 ERCP 失败时进行，并提供了一种替代经皮或手术减压以及 EUS 引导建立胆肠瘘的引流选择。
