Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector -12, Chandigarh, 160012, India.
Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
Surg Endosc. 2023 Jan;37(1):298-308. doi: 10.1007/s00464-022-09495-1. Epub 2022 Aug 8.
Patients with moderate-severe cholangitis require urgent/early biliary drainage and failed endoscopic retrograde cholangiopancreatography (ERCP) warrants use of percutaneous drainage. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved as an effective salvage modality but its safety and efficacy data in moderate-severe cholangitis are limited.
All consecutive moderate-severe cholangitis patients, with failed/technically non-feasible ERCP requiring EUS-BD in two tertiary care centers were included. Baseline laboratory and demographic parameters were documented. Technical and clinical success were primary outcome measures. Additionally, effective biliary drainage, adverse events due to procedure, hospital stay, ICU stay, and mortality were noted.
Of the 49 patients (23 male; 46.9%) presenting with moderate/severe cholangitis, 23 (46.9%) had severe cholangitis. The median Charleston comorbidity index was 7.0 (IQR 2.0). Majority had malignant disease (87.8%) and 25 (51.0%) had inaccessible papilla. Technical success was achieved in 48 cases (98.0%), while clinical success with improvement of cholangitis was noted in 44 of 48 cases (91.7%). Effective biliary drainage was noted in 85.4% (41/48) cases. Adverse events in the form of mostly bleeding and bile leak were noted in 5 cases (10.2%) but managed conservatively. Distal obstruction exhibited significantly better clinical success (100% vs. 78.9%; p = 0.02) than hilar obstruction. Severe cholangitis had significantly lower clinical success (81.8% vs. 100%; p = 0.04) than moderate cholangitis.
EUS-BD can be a safe and effective alternative option for patients with moderate to severe cholangitis, even with significant pre-morbid conditions, with acceptable adverse events rate.
患有中重度胆管炎的患者需要紧急/早期胆道引流，如果内镜逆行胰胆管造影（ERCP）失败，则需要进行经皮引流。虽然内镜超声引导下胆道引流（EUS-BD）已成为一种有效的挽救方式，但在中重度胆管炎中的安全性和疗效数据有限。
本研究纳入了在两家三级护理中心因 ERCP 失败/技术上不可行而需要 EUS-BD 的连续中重度胆管炎患者。记录了基线实验室和人口统计学参数。主要观察指标为技术和临床成功率。此外，还记录了有效的胆道引流、与操作相关的不良事件、住院时间、重症监护病房（ICU）住院时间和死亡率。
在 49 例中重度胆管炎患者中（23 例男性；46.9%），23 例（46.9%）患有重度胆管炎。Charleston 合并症指数中位数为 7.0（IQR 2.0）。大多数患者患有恶性肿瘤（87.8%），25 例（51.0%）存在无法接近的乳头。48 例（98.0%）患者获得了技术成功，48 例中有 44 例（91.7%）胆管炎改善，实现了临床成功。41 例（85.4%）患者获得了有效的胆道引流。5 例（10.2%）患者出现了以出血和胆漏为主的不良事件，但均经保守治疗得到控制。远侧胆管梗阻的临床成功率显著高于近侧胆管梗阻（100%比 78.9%；p=0.02）。重度胆管炎的临床成功率显著低于中度胆管炎（81.8%比 100%；p=0.04）。
即使存在严重的基础疾病，EUS-BD 也是中重度胆管炎患者安全且有效的治疗选择，具有可接受的不良事件发生率。
