Caillol Fabrice, Bosshardt Coline, Reimao Sylvia, Francioni Ellen, Pesenti Christian, Bories Erwan, Ratone Jean Philippe, Giovannini Marc
Endoscopy Departement, Endoscopy Unit, Paoli Calmettes Institute, Marseille, France.
Endosc Ultrasound. 2019 May-Jun;8(3):199-203. doi: 10.4103/eus.eus_64_18.
EUS-guided biliary drainage is now comparable to percutaneous drainage. This technique can be used in cases of complex drainage of the hilum, mainly for salvage therapy to drain the left liver. In cases of inaccessible papilla or altered anatomy, EUS-guided biliary drainage for hilar stenosis of the liver could be used as the first approach. However, this technique has limited applicability for the right liver. In this feasibility study, we reported drainage of the right liver using the bridge technique and hepaticogastrostomy.
This retrospective study was based on a prospective registry from January 2013 to February 2017. Patients with inaccessible papilla due to altered anatomy or duodenal invasion and drainage under EUS guidance and bridge technique without previous biliary drainage were included in the study. The bridge technique was used to place an uncovered biliary stent between the right and left liver. The left liver was drained with a hepaticogastrostomy.
Twelve patients were included in the study. Stenosis was Type II for nine, IIIA for two, and Type IV for one patient. Technical and clinical success was 100% and 83%, respectively. Morbidity was 33% (four patients), including three with abdominal pain managed conservatively and one with a percutaneous salvage drainage. Postoperative mortality was 8% (uncontrolled sepsis). The mean survival was 6 months. Chemotherapy could be administered in 70% (seven) patients in cases of clinical success.
The bridge technique under EUS guidance could be a first alternative for draining malignant hilar stenosis in cases of the inaccessible papilla.
超声内镜引导下胆道引流目前已可与经皮引流相媲美。该技术可用于肝门部复杂引流情况，主要用于挽救性治疗以引流左肝。在乳头难以触及或解剖结构改变的情况下，超声内镜引导下肝门部狭窄的胆道引流可作为首选方法。然而，该技术对右肝的适用性有限。在本可行性研究中，我们报告了使用桥接技术和肝胃吻合术对右肝进行引流的情况。
本回顾性研究基于2013年1月至2017年2月的前瞻性登记数据。纳入因解剖结构改变或十二指肠侵犯导致乳头难以触及且在超声内镜引导和桥接技术下进行引流且此前未进行过胆道引流的患者。采用桥接技术在右肝和左肝之间放置一枚未覆膜胆道支架。通过肝胃吻合术对左肝进行引流。
12例患者纳入研究。9例患者狭窄为II型，2例为IIIA型，1例为IV型。技术成功率和临床成功率分别为100%和83%。并发症发生率为33%（4例患者），其中3例腹痛患者经保守治疗，1例患者进行了经皮挽救性引流。术后死亡率为8%（因败血症未得到控制）。平均生存期为6个月。临床成功的病例中，70%（7例）患者可进行化疗。
在乳头难以触及的情况下，超声内镜引导下的桥接技术可能是引流恶性肝门部狭窄的首选替代方法。
