Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, 589-8511, Japan.
Second Department of Internal Medicine, School of Medicine, Wakayama Medical University, Wakayama, Japan.
Surg Endosc. 2017 Nov;31(11):4764-4772. doi: 10.1007/s00464-017-5553-6. Epub 2017 Apr 19.
Treatment of unresectable malignant hilar biliary stricture (UMHBS) is challenging, especially after failure of repeated transpapillary endoscopic stenting. Endoscopic ultrasonography-guided intrahepatic biliary drainage (EUS-IBD) is a recent technique for intrahepatic biliary decompression, but indications for its use for complex hilar strictures have not been well studied. The aim of this study was to assess the feasibility and safety of EUS-IBD for UMHBS after failed transpapillary re-intervention.
Retrospective analysis of all consecutive patients with UMHBS of Bismuth II grade or higher who, between December 2008 and May 2016, underwent EUS-IBD after failed repeated transpapillary interventions. The technical success, clinical success, and complication rates were evaluated. Factors associated with clinical ineffectiveness of EUS-IBD were explored.
A total of 30 patients (19 women, median age 66 years [range 52-87]) underwent EUS-IBD for UMHBS during the study period. Hilar biliary stricture morphology was classified as Bismuth II, III, or IV in 5, 13, and 12 patients, respectively. The median number of preceding endoscopic interventions was 4 (range 2-14). EUS-IBD was required because the following procedures failed: duodenal scope insertion (n = 4), accessing the papilla after duodenal stent insertion (n = 5), or achieving desired intrahepatic biliary drainage (n = 21). Technical success with EUS-IBD was achieved in 29 of 30 patients (96.7%) and clinical success was attained in 22 of these 29 (75.9%). Mild peritonitis occurred in three of 30 (10%) and was managed conservatively. Stent dysfunction occurred in 23.3% (7/30). There was no procedure-related mortality. On multivariable analysis, Bismuth IV stricture predicted clinical ineffectiveness (odds ratio = 12.7, 95% CI 1.18-135.4, P = 0.035).
EUS-IBD may be a feasible and effective rescue alternative with few major complications after failed transpapillary endoscopic re-intervention in patients with UMHBS, particularly for Bismuth II or III strictures.
治疗不可切除的恶性肝门胆管狭窄（UMHBS）具有挑战性，尤其是在多次经内镜逆行胰胆管造影术（ERCP）支架置入失败后。超声内镜引导下经肝内胆管引流术（EUS-IBD）是一种用于肝内胆管减压的新技术，但尚未对其用于复杂肝门狭窄的适应证进行充分研究。本研究旨在评估 EUS-IBD 治疗经 ERCP 反复介入治疗后失败的 UMHBS 的可行性和安全性。
回顾性分析 2008 年 12 月至 2016 年 5 月期间，因 Bismuth II 级或更高级别的 UMHBS 而行 EUS-IBD 治疗且此前经 ERCP 重复介入治疗失败的所有连续患者。评估技术成功率、临床成功率和并发症发生率。探讨与 EUS-IBD 临床无效相关的因素。
研究期间，共有 30 例（19 名女性，中位年龄 66 岁[范围 52-87 岁]）因 UMHBS 接受了 EUS-IBD 治疗。肝门胆管狭窄形态学分类为 Bismuth II、III 或 IV 型的患者分别为 5、13 和 12 例。先前内镜介入的中位数为 4 次（范围 2-14 次）。进行 EUS-IBD 的原因是：十二指肠镜插入失败（n=4）、十二指肠支架置入后乳头无法进入（n=5）或无法实现理想的肝内胆管引流（n=21）。30 例患者中，29 例（96.7%）成功实施 EUS-IBD 技术，29 例中有 22 例（75.9%）达到临床成功。30 例中有 3 例（10%）发生轻度腹膜炎，经保守治疗后痊愈。支架功能障碍发生率为 23.3%（7/30）。无与操作相关的死亡。多变量分析显示，Bismuth IV 型狭窄是临床无效的预测因素（比值比=12.7，95%CI 1.18-135.4，P=0.035）。
对于经 ERCP 反复内镜介入治疗后失败的 UMHBS 患者，EUS-IBD 是一种可行且有效的治疗选择，并发症少，尤其是对于 Bismuth II 或 III 型狭窄。
