Clinical Endoscopy

Systematic Review and Meta-analysis

Efficacy of endoscopic ultrasound-guided biliary drainage of malignant biliary obstruction: a systematic review and meta-analysis of randomized controlled trials: Yousaf Zafar, Hafsa Azam, Muhammad Abdullah Bin Azhar, Fabeeha Shaheen, Syed Sarmad Javaid, Laila Manzoor, Muaaz Masood, Rajesh Krishnamoorthi; Received July 3, 2024 Accepted September 24, 2024 Published online February 24, 2025; DOI: https://doi.org/10.5946/ce.2024.183 [Epub ahead of print]

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Malignant biliary obstruction is a major clinical challenge. We assessed the efficacy of endoscopic ultrasound-guided biliary drainage (EUS-BD) compared with that of endoscopic retrograde cholangiopancreatography biliary drainage (ERCP-BD) or percutaneous transhepatic biliary drainage (PTBD).
Methods
We searched for randomized controlled trials comparing EUS-BD with ERCP or PTBD in treating malignant biliary obstruction. Using random-effects models, we synthesized risk ratios (RRs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs). A subgroup analysis was performed using a comparator (ERCP or PTBD).
Results
EUS-BD significantly reduced the risk of stent dysfunction (RR, 0.46; 95% CI, 0.33–0.64), with consistent results in subgroup analysis for ERCP (RR, 0.54; 95% CI, 0.35–0.84) and PTBD (RR, 0.37; 95% CI, 0.22–0.61). It also lowered the risk of post-procedure pancreatitis (RR, 0.24; 95% CI, 0.07–0.83) and reduced tumor ingrowth or overgrowth risk (RR, 0.27; 95% CI, 0.11–0.65), even when compared to ERCP alone (RR, 0.28; 95% CI, 0.11–0.70). EUS-BD demonstrated a lower risk of adverse events compared to PTBD (RR, 0.37; 95% CI, 0.14–0.97) and reduced length of hospital stay (WMD, –1.03; 95% CI, –1.53 to –0.53) when compared to ERCP.
Conclusions
EUS-BD outperformed ERCP-BD and PTBD in reducing stent dysfunction, postprocedural pancreatitis, and tumor ingrowth or overgrowth.

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Review

Endoscopic biliary drainage for distal bile duct obstruction due to pancreatic cancer: Masahiro Itonaga, Masayuki Kitano; Clin Endosc 2025;58(1):40-52. Published online September 26, 2024; DOI: https://doi.org/10.5946/ce.2023.294

Abstract PDF PubReader ePub: Approximately 60% of pancreatic cancers occur in the pancreatic head and may present as obstructive jaundice due to bile duct invasion. Obstructive jaundice often leads to poor general conditions and acute cholangitis, interfering with surgery and chemotherapy and requiring biliary drainage. The first choice of treatment for biliary drainage is the endoscopic transpapillary approach. In unresectable tumors, self-expandable metal stents (SEMSs) are most commonly used and are classified into uncovered and covered SEMSs. Recently, antireflux metal stents and large- or small-diameter SEMSs have become commercially available, and their usefulness has been reported. Plastic stents are infrequently used in patients with resectable biliary obstruction; however, owing to the recent trend in preoperative chemotherapy, SEMSs are frequently used because of the long time to recurrent biliary obstruction. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is often performed in patients who are not eligible for the transpapillary approach, and favorable outcomes have been reported. Different EUS-BD techniques and specialized stents have been developed and can be safely used in high-volume centers. The indications for EUS-BD are expected to further expand in the future.

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Original Articles

Hepatobiliary scintigraphy of bile excretion after endoscopic ultrasound-guided hepaticogastrostomy for malignant biliary obstruction: a retrospective study in Japan: Masanori Yamada, Kazuo Hara, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Yasuhiro Kuraishi, Takafumi Yanaidani, Sho Ishikawa, Tsukasa Yasuda, Toshitaka Fukui; Clin Endosc 2024;57(6):798-806. Published online August 20, 2024; DOI: https://doi.org/10.5946/ce.2023.291

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Hepatobiliary scintigraphy (HBS) is used to evaluate bile excretion. This study aimed to evaluate biliary excretion during endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using HBS.
Methods
We retrospectively evaluated 78 consecutive patients with malignant extrahepatic biliary obstruction, who underwent HBS after EUS-HGS between April 2015 and July 2022. The peak time and decay rate were scored with 0, 1, or 2 points based on thresholds of 20 and 35 minutes, and 10% and 50%, respectively. A total score of 4 or 3 was considered indicative of good bile excretion, whereas scores of 2, 1, or 0 indicated poor bile excretion.
Results
The good and poor bile excretion groups included 40 and 38 cases, respectively. The group with good bile excretion had a significantly longer time to recurrent biliary obstruction compared to the poor bile excretion group (not reached vs. 124 days, p=0.026). Multivariate analysis identified the site of obstruction as a significant factor influencing good bile excretion (odds ratio, 3.39; 95% confidence interval, 1.01–11.4, p=0.049), with superior bile excretion observed in cases involving upper biliary obstruction compared to middle or lower biliary obstruction.
Conclusions
In patients with malignant biliary obstruction who underwent HGS, the site of obstruction is significantly associated with stent patency.

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Prophylactic endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis induced after metallic stent placement for malignant biliary strictures: a retrospective study in Japan: Fumisato Kozakai, Yoshihide Kanno, Shinsuke Koshita, Takahisa Ogawa, Hiroaki Kusunose, Toshitaka Sakai, Keisuke Yonamine, Kazuaki Miyamoto, Haruka Okano, Yuto Matsuoka, Kento Hosokawa, Hidehito Sumiya, Kei Ito; Clin Endosc 2024;57(5):647-655. Published online May 17, 2024; DOI: https://doi.org/10.5946/ce.2023.284

Graphical Abstract Abstract PDF PubReader ePub

Background
/Aims: Endoscopic biliary drainage using self-expandable metallic stents (SEMSs) for malignant biliary strictures occasionally induces acute cholecystitis (AC). This study evaluated the efficacy of prophylactic gallbladder stents (GBS) during SEMS placement.
Methods
Among 158 patients who underwent SEMS placement for malignant biliary strictures between January 2018 and March 2023, 30 patients who attempted to undergo prophylactic GBS placement before SEMS placement were included.
Results
Technical success was achieved in 21 cases (70.0%). The mean diameter of the cystic duct was more significant in the successful cases (6.5 mm vs. 3.7 mm, p<0.05). Adverse events occurred for 7 patients (23.3%: acute pancreatitis in 7; non-obstructive cholangitis in 1; perforation of the cystic duct in 1 with an overlap), all of which improved with conservative treatment. No patients developed AC when the GBS placement was successful, whereas 25 of the 128 patients (19.5%) without a prophylactic GBS developed AC during the median follow-up period of 357 days (p=0.043). In the multivariable analysis, GBS placement was a significant factor in preventing AC (hazard ratio, 0.61; 95% confidence interval, 0.37–0.99; p=0.045).
Conclusions
GBS may contribute to the prevention of AC after SEMS placement for malignant biliary strictures.

Citations

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Risk Factors for Cholecystitis After Self-expandable Metallic Stent Placement for Malignant Distal Biliary Obstruction
Hashem Albunni, Azizullah Beran, Nwal Hadaki, Mark A. Gromski, Mohammad Al-Haddad
Journal of Clinical Gastroenterology.2025;[Epub] CrossRef
Risk factors for infection following particle stent placement in obstructive jaundice patients: A retrospective analysis
Gang Wang, Rui Qi
Current Problems in Surgery.2025; 67: 101775. CrossRef
Technical challenges and safety of prophylactic gallbladder stenting with metallic biliary stenting
Masood Muhammad Karim, Om Parkash
Clinical Endoscopy.2024; 57(6): 841. CrossRef

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Review

Forward viewing liner echoendoscopy for therapeutic interventions: Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara; Clin Endosc 2024;57(2):175-180. Published online February 29, 2024; DOI: https://doi.org/10.5946/ce.2023.271

Abstract PDF PubReader ePub

Therapeutic endoscopic ultrasonography (EUS) procedures using the forward-viewing convex EUS (FV-EUS) have been reviewed based on the articles reported to date. The earliest reported procedure is the drainage of pancreatic pseudocysts using FV-EUS. However, the study on drainage of pancreatic pseudocysts focused on showing that drainage is possible with FV-EUS rather than leveraging its features. Subsequently, studies describing the characteristics of FV-EUS have been reported. By using FV-EUS in EUS-guided choledochoduodenostomy, double punctures in the gastrointestinal tract can be avoided. In postoperative modified anatomical cases, using the endoscopic function of FV-EUS, procedures such as bile duct drainage from anastomosis, pancreatic duct drainage from the afferent limb, and abscess drainage from the digestive tract have been reported. When a perpendicular puncture to the gastrointestinal tract is required or when there is a need to insert the endoscope deep into the gastrointestinal tract, FV-EUS is considered among the options.

Citations

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Stent misdeployment and factors associated with failure in endoscopic ultrasound-guided choledochoduodenostomy: analysis of the combined datasets from two randomized trials
Yen-I Chen, Clara Long, Anand V. Sahai, Bertrand Napoleon, Gianfranco Donatelli, Rastislav Kunda, Myriam Martel, Shannon M. Chan, Paolo G. Arcidiacono, Eric Lam, Pradermchai Kongkam, Nauzer Forbes, Alberto Larghi, Jeffrey D. Mosko, Schalk Van der Merwe, S
Endoscopy.2025; 57(04): 330. CrossRef
Forward-viewing echoendoscope provides single sessional three biliary drainage routes in a patient with pancreatoduodenectomy
Tesshin Ban, Yoshimasa Kubota, Shun Sasoh, Tomoaki Ando, Takashi Joh
Endoscopy.2025; 57(S 01): E333. CrossRef
Endoscopic ultrasound-guided pancreatic duct drainage: Progress and future outlook
Si-Yao Wang, Si-Qiao Zhao, Shu-Peng Wang, Yue Zhang, Si-Yu Sun, Sheng Wang
World Journal of Gastrointestinal Surgery.2025;[Epub] CrossRef
Failed endoscopic ultrasound‐guided gallbladder drainage across the duodenal covered metallic stent salvaged by using a forward‐viewing linear echoendoscope
Tesshin Ban, Yoshimasa Kubota, Takashi Joh
Digestive Endoscopy.2024; 36(12): 1389. CrossRef

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Original Articles

The efficacy of a novel integrated outside biliary stent and nasobiliary drainage catheter system for acute cholangitis: a single center pilot study: Naosuke Kuraoka, Tetsuro Ujihara, Hiromi Kasahara, Yuto Suzuki, Shun Sakai, Satoru Hashimoto; Clin Endosc 2023;56(6):795-801. Published online April 11, 2023; DOI: https://doi.org/10.5946/ce.2022.289

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Endoscopic biliary drainage is the gold standard treatment for cholangitis. The two methods of biliary drainage are endoscopic biliary stenting and nasobiliary drainage. A novel integrated outside biliary stent and nasobiliary drainage catheter system (UMIDAS NB stent; Olympus Medical Systems) was recently developed. In this study, we evaluated the efficacy of this stent in the treatment of cholangitis caused by common bile duct stones or distal bile duct strictures.
Methods
We conducted a retrospective pilot study by examining the medical records of patients who required endoscopic biliary drainage for cholangitis due to common bile duct stones or distal bile duct strictures, and who were treated with a UMIDAS NB stent, between December 2021 and July 2022.
Results
Records of 54 consecutive patients were reviewed. Technical and clinical success rates were 47/54 (87.0%) and 52/54 (96.3%), respectively. Adverse events were observed in 12 patients, with six patients experiencing pancreatitis as an adverse event, following endoscopic retrograde cholangiopancreatography (ERCP). Regarding late adverse events, five cases of biliary stent migration into the bile duct were observed. Disease-related death occurred in one patient.
Conclusions
The outside-type UMIDAS NB stent is an efficacious new method for biliary drainage and can be applied to many indications.

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Role of interventional endoscopic ultrasound in a developing country: Hasan Maulahela, Nagita Gianty Annisa, Achmad Fauzi, Kaka Renaldi, Murdani Abdullah, Marcellus Simadibrata, Dadang Makmun, Ari Fahrial Syam; Clin Endosc 2023;56(1):100-106. Published online January 17, 2023; DOI: https://doi.org/10.5946/ce.2022.058

Abstract PDF PubReader ePub

Background
/Aims: Endoscopic ultrasound (EUS) has become an essential diagnostic and therapeutic tool. EUS was introduced in 2013 in Indonesia and is considered relatively new. This study aimed to describe the current role of interventional EUS at our hospital as a part of the Indonesian tertiary health center experience.
Methods
This retrospective study included all patients who underwent interventional EUS (n=94) at our center between January 2015 and December 2020. Patient characteristics, technical success, clinical success, and adverse events associated with each type of interventional EUS procedure were evaluated.
Results
Altogether, 94 interventional EUS procedures were performed at our center between 2015 and 2020 including 75 cases of EUS-guided biliary drainage (EUS-BD), 14 cases of EUS-guided pancreatic fluid drainage, and five cases of EUS-guided celiac plexus neurolysis. The technical and clinical success rates of EUS-BD were 98.6% and 52%, respectively. The technical success rate was 100% for both EUS-guided pancreatic fluid drainage and EUS-guided celiac plexus neurolysis. The adverse event rates were 10.6% and 7.1% for EUS-BD and EUS-guided pancreatic fluid drainage, respectively.
Conclusions
EUS is an effective and safe tool for the treatment of gastrointestinal and biliary diseases. It has a low rate of adverse events, even in developing countries.

Citations

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EUS-guided interventional therapies for pancreatic diseases
Rongmin Xu, Kai Zhang, Nan Ge, Siyu Sun
Frontiers in Medicine.2024;[Epub] CrossRef

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Outcomes of Endoscopic Ultrasound-Guided Biliary Drainage in Patients Undergoing Antithrombotic Therapy: Nozomi Okuno, Kazuo Hara, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Hiroki Koda, Masahiro Tajika, Tsutomu Tanaka, Sachiyo Onishi, Keisaku Yamada, Akira Miyano, Daiki Fumihara, Moaz Elshair; Clin Endosc 2021;54(4):596-602. Published online February 17, 2021; DOI: https://doi.org/10.5946/ce.2020.194

Abstract PDF PubReader ePub

Background
/Aims: The Japan Gastroenterological Endoscopy Society (JGES) has published guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. These guidelines classify endoscopic ultrasound-guided biliary drainage (EUS-BD) as a high-risk procedure. Nevertheless, the bleeding risk of EUS-BD in patients undergoing antithrombotic therapy is uncertain. Therefore, this study aimed to assess the bleeding risk in patients undergoing antithrombotic therapy.
Methods
This single-center retrospective study included 220 consecutive patients who underwent EUS-BD between January 2013 and December 2018. We managed the withdrawal and continuation of antithrombotic agents according to the JGES guidelines. We compared the bleeding event rates among patients who received and those who did not receive antithrombotic agents.
Results
A total of 18 patients (8.1%) received antithrombotic agents and 202 patients (91.8%) did not. Three patients experienced bleeding events, with an overall bleeding event rate of 1.3% (3/220): one patient was in the antithrombotic group (5.5%) and two patients were in the non-antithrombotic group (0.9%) (p=0.10). All cases were moderate. The sole thromboembolic event (0.4%) was a cerebral infarction in a patient in the non-antithrombotic group.
Conclusions
The rate of EUS-BD-related bleeding events was low. Even in patients receiving antithrombotic therapy, the bleeding event rates were not significantly different from those in patients not receiving antithrombotic therapy.

Citations

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The New Potential for Using Franseen Needles in Interventional EUS
Nozomi Okuno, Kazuo Hara, Shin Haba, Takamichi Kuwahara, Toshitaka Fukui, Minako Urata, Yoshitaro Yamamoto, Takashi Kondo
Internal Medicine.2024; 63(20): 2723. CrossRef
International Digestive Endoscopy Network consensus on the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy
Seung Joo Kang, Chung Hyun Tae, Chang Seok Bang, Cheol Min Shin, Young-Hoon Jeong, Miyoung Choi, Joo Ha Hwang, Yutaka Saito, Philip Wai Yan Chiu, Rungsun Rerknimitr, Christopher Khor, Vu Van Khien, Kee Don Choi, Ki-Nam Shim, Geun Am Song, Oh Young Lee
Clinical Endoscopy.2024; 57(2): 141. CrossRef
IDEN Consensus on Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy
Seung Joo Kang, Chung Hyun Tae, Chang Seok Bang, Cheol Min Shin, Young-Hoon Jeong, Miyoung Choi, Joo Ha Hwang, Yutaka Saito, Philip Wai Yan Chiu, Rungsun Rerknimitr, Christopher Khor, Vu Van Khien, Kee Don Choi, Ki-Nam Shim, Geun Am Song, Oh Young Lee
The Korean Journal of Gastroenterology.2024; 83(6): 217. CrossRef
International Digestive Endoscopy Network Consensus on the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy
Seung Joo Kang, Chung Hyun Tae, Chang Seok Bang, Cheol Min Shin, Young-Hoon Jeong, Miyoung Choi, Joo Ha Hwang, Yutaka Saito, Philip Wai Yan Chiu, Rungsun Rerknimitr, Christopher Khor, Vu Van Khien, Kee Don Choi, Ki-Nam Shim, Geun Am Song, Oh Young Lee
Gut and Liver.2024; 18(5): 764. CrossRef
Novel drill dilator facilitates endoscopic ultrasound‐guided hepaticogastrostomy
Nozomi Okuno, Kazuo Hara, Shin Haba, Takamichi Kuwahara, Yasuhiro Kuraishi, Takafumi Yanaidani, Sho Ishikawa, Tsukasa Yasuda, Masanori Yamada, Toshitaka Fukui
Digestive Endoscopy.2023; 35(3): 389. CrossRef
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Takeshi Ogura
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Akihisa Ohno, Nao Fujimori, Noboru Harada
Endoscopic Ultrasound.2023;[Epub] CrossRef
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Suprabhat Giri, Babu P. Mohan, Vaneet Jearth, Aditya Kale, Sumaswi Angadi, Shivaraj Afzalpurkar, Sidharth Harindranath, Sridhar Sundaram
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Shyam Vedantam, Sunil Amin
Clinics in Liver Disease.2022; 26(1): 101. CrossRef
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Nozomi Okuno, Kazuo Hara, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Yasuhiro Kuraishi, Masahiro Tajika, Tsutomu Tanaka, Sachiyo Onishi, Keisaku Yamada, Daiki Fumihara, Takafumi Yanaidani, Sho Ishikawa, Masanori Yamada, Tsukasa Yasuda, Moaz Elshair
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Risk Factors for Pancreatitis and Cholecystitis after Endoscopic Biliary Stenting in Patients with Malignant Extrahepatic Bile Duct Obstruction: Ga Hee Kim, Si Kyong Ryoo, Jae Keun Park, Joo Kyung Park, Kwang Hyuck Lee, Kyu Taek Lee, Jong Kyun Lee; Clin Endosc 2019;52(6):598-605. Published online May 28, 2019; DOI: https://doi.org/10.5946/ce.2018.177

Abstract PDF PubReader ePub

Background
/Aims: For the treatment of malignant biliary obstruction, endoscopic retrograde biliary drainage (ERBD) has been widely accepted as a standard procedure. However, post-ERBD complications can affect the lives of patients. The purpose of this study was to identify the predictive factors for these complications, including the patient’s status, cancer status, and stent type.
Methods
This was a retrospective analysis conducted in a single tertiary hospital from January 2007 to July 2017. The following variables were evaluated: sex, age, body mass index, cancer type, history of pancreatitis, gallbladder stone, previous biliary stenting, precut papillotomy, stent type, contrast injection into the pancreatic duct or gallbladder, cystic duct invasion by the tumor, and occlusion of the cystic duct orifice by a metal stent.
Results
Multivariate analysis showed that contrast injection into the pancreatic duct was a risk factor for pancreatitis. Patients with a history of bile drainage showed a lower risk of pancreatitis. For cholecystitis, the analysis revealed contrast injection into the gallbladder and cystic duct invasion by the tumor as important predictive factors. Metal stents showed a greater risk of post-procedure pancreatitis than plastic stents, but did not affect the incidence of cholecystitis.
Conclusions
Considering that contrast injection is the most important factor for both complications, a careful approach by the physician is essential in preventing the occurrence of any complications. Further, choosing the type of stent is an important factor for patients at a risk of post-procedure pancreatitis.

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Risk factors for biliary tract events during elective cholecystectomy waiting time after endoscopic retrograde cholangiopancreatography for choledocholithiasis
Tatsunori Satoh, Junichi Kaneko, Shinya Kawaguchi, Yuya Ishiguro, Shinya Endo, Naofumi Shirane, Hideyuki Kanemoto, Takanori Yamada, Kazuya Ohno
DEN Open.2025;[Epub] CrossRef
Risk Factors for Cholecystitis After Self-expandable Metallic Stent Placement for Malignant Distal Biliary Obstruction
Hashem Albunni, Azizullah Beran, Nwal Hadaki, Mark A. Gromski, Mohammad Al-Haddad
Journal of Clinical Gastroenterology.2025;[Epub] CrossRef
The usefulness of percutaneous bile duct metal stent insertion for malignant biliary obstruction: a retrospective study
Hideki Izumi, Hisamichi Yoshii, Rika Fujino, Shigeya Takeo, Masaya Mukai, Junichi Kaneko, Hiroyasu Makuuchi
BMC Gastroenterology.2025;[Epub] CrossRef
Endoscopic Management of Malignant Biliary Obstruction
Woo Hyun Paik, Do Hyun Park
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Jing Song, Jun Deng, Feng Wen, Piero Chirletti
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Nga T. Nguyen, Hasan A. Khan, Kian Abdul-Baki, Woongsoon Choi, Neel K. Shroff, Zahra Akhtar, Peeyush Bhargava
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Yuki Tanisaka, Masafumi Mizuide, Akashi Fujita, Tomoya Ogawa, Hiromune Katsuda, Youichi Saito, Kazuya Miyaguchi, Ryuichiro Araki, Shomei Ryozawa
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Dilated main pancreatic duct can be a negative predictor of pancreatitis related to biliary SEMS insertion across the papilla
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Focused Review Series: Expanding Indication: Interventional Endoscopic Management for Pancreaticobiliary Diseaseses

Endoscopic Ultrasound-Guided Biliary Drainage for Benign Biliary Diseases: Yousuke Nakai, Hirofumi Kogure, Hiroyuki Isayama, Kazuhiko Koike; Clin Endosc 2019;52(3):212-219. Published online March 14, 2019; DOI: https://doi.org/10.5946/ce.2018.188

Abstract PDF PubReader ePub

Although endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for benign biliary diseases, this procedure is technically difficult in some conditions such as a surgically altered anatomy and gastric outlet obstruction. After a failed ERCP, a surgical or a percutaneous approach is selected as a rescue procedure; however, various endoscopic ultrasound (EUS)-guided interventions are increasingly utilized in pancreatobiliary diseases, including EUS-guided rendezvous for failed biliary cannulation, EUS-guided antegrade treatment for stone management, and EUS-guided hepaticogastrostomy for anastomotic strictures in patients with a surgically altered anatomy. There are some technical hurdles in EUS-guided interventions for benign biliary diseases owing to the difficulty in puncturing a relatively small bile duct and in subsequent guidewire manipulation, as well as the lack of dedicated devices. A recent major advancement in this field is the introduction of a 2-step approach, in which EUS-guided drainage is placed in the first session and antegrade treatment is performed in subsequent sessions. This approach allows the use of various techniques such as mechanical lithotripsy and cholangioscopy without a risk of bile leak. In summary, EUS-guided interventions are among the treatment options for benign biliary diseases; however, standardization of the procedure and development of a treatment algorithm are needed.

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Échoendoscopie biliaire et pancréatique thérapeutique
G. Marcellier, F. Prat
EMC - Hépatologie.2025; 40(1): 1. CrossRef
Successful reinterventional drainage via endoscopic ultrasound-guided cannulation with anastomotic identification
Daisuke Namima, Toshio Fujisawa, Yusuke Takasaki, Ko Tomishima, Shigeto Ishii, Hideki Kobara, Hiroyuki Isayama
Endoscopy.2025; 57(S 01): E159. CrossRef
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Juan Antonio Chirinos-Vega, Oscar Eduardo Ponce de León Molina
Revista de Gastroenterología del Perú.2025; 45(1): 79. CrossRef
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Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction: Yousuke Nakai, Hirofumi Kogure, Hiroyuki Isayama, Kazuhiko Koike; Clin Endosc 2019;52(3):220-225. Published online November 29, 2018; DOI: https://doi.org/10.5946/ce.2018.094

Abstract PDF PubReader ePub

Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO) and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneous transhepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary stricture and internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUS-guidance include a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. The aim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches such as endoscopic transpapillary biliary drainage and PTBD.

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Case Report

Pneumoperitoneum after Endoscopic Duodenal Stent Insertion in a Patient with Percutaneous Transhepatic Biliary Drainage and Biliary Stent: A Case Report: Jinwoo Choi, Min Ji Lee, Hyodeok Lee, Yook Kim, Joung-Ho Han, Seon Mee Park; Clin Endosc 2019;52(3):288-292. Published online August 29, 2018; DOI: https://doi.org/10.5946/ce.2018.128

Abstract PDF PubReader ePub

Early removal of a percutaneous transhepatic biliary drainage (PTBD) tube commonly causes pneumoperitoneum. However, we encountered a patient who developed pneumoperitoneum even with an indwelling PTBD tube. An 84-year-old man was admitted with type III combined duodenal and biliary obstruction secondary to metastatic bladder cancer. A biliary stent was placed using a percutaneous approach, and a duodenal stent was placed endoscopically. A large amount of subphrenic free air was detected after the procedures. Laboratory tests indicated intestinal perforation; however, peritoneal signs were absent. The patient was treated conservatively using an indwelling Levin tube. Seven days later, the massive amount of subphrenic free air disappeared. Follow-up tubography revealed unrestricted bile flow into the small intestine, and the PTBD tube was removed. Prolonged endoscopic procedures in patients with a PTBD tract communicating with the gastrointestinal tract can precipitate pneumoperitoneum. Clinicians should be careful to avoid misdiagnosing this condition as intestinal perforation.

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Focused Review Series: EUS-Guided Therapeutic Interventions

Endoscopic Ultrasound-Guided Biliary Access, with Focus on Technique and Practical Tips: Woo Hyun Paik, Do Hyun Park; Clin Endosc 2017;50(2):104-111. Published online March 30, 2017; DOI: https://doi.org/10.5946/ce.2017.036

Abstract PDF PubReader ePub

In 1980, endoscopic ultrasound (EUS) was introduced as a diagnostic tool for evaluation of the pancreas. Since the introduction of curvilinear-array echoendoscopy, EUS has been used for a variety of gastrointestinal interventions, including fine needle aspiration, tumor ablation, and pancreatobiliary access. One of the main therapeutic roles of EUS is biliary drainage as an alternative to endoscopic retrograde biliary drainage (ERBD) or percutaneous transhepatic biliary drainage (PTBD). This article summarizes three different methods of EUS-guided biliary access, with focus on technique and practical tips.

Citations

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Original Article

The Clinical Usefulness of Simultaneous Placement of Double Endoscopic Nasobiliary Biliary Drainage: Hong Jun Kim, Sung Koo Lee, Choong Heon Ryu, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Myung-Hwan Kim; Clin Endosc 2015;48(6):542-548. Published online November 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.6.542

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Background
/Aims: To evaluate the technical feasibility and clinical efficacy of double endoscopic nasobiliary drainage (ENBD) as a new method of draining multiple bile duct obstructions.
Methods
A total of 38 patients who underwent double ENBD between January 2004 and February 2010 at the Asan Medical Center were retrospectively analyzed. We evaluated indications, laboratory results, and the clinical course.
Results
Of the 38 patients who underwent double ENBD, 20 (52.6%) had Klatskin tumors, 12 (31.6%) had hepatocellular carcinoma, 3 (7.9%) had strictures at the anastomotic site following liver transplantation, and 3 (7.9%) had acute cholecystitis combined with cholangitis. Double ENBD was performed to relieve multiple biliary obstruction in 21 patients (55.1%), drain contrast agent filled during endoscopic retrograde cholangiopancreatography in 4 (10.5%), obtain cholangiography in 4 (10.5%), drain hemobilia in 3 (7.9%), relieve Mirizzi syndrome with cholangitis in 3 (7.9%), and relieve jaundice in 3 (7.9%).
Conclusions
Double ENBD may be useful in patients with multiple biliary obstructions.

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High-throughput metabolomics reveals the perturbed metabolic pathways and biomarkers of Yang Huang syndrome as potential targets for evaluating the therapeutic effects and mechanism of geniposide
Heng Fang, Aihua Zhang, Xiaohang Zhou, Jingbo Yu, Qi Song, Xijun Wang
Frontiers of Medicine.2020; 14(5): 651. CrossRef
Can Endoscopic Nasobiliary Drainage Involving Two Catheters Be Used to Treat Various Conditions?
Dong Wook Lee, Ho Gak Kim
Clinical Endoscopy.2015; 48(6): 464. CrossRef

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Focused Review Series: Advanced Endoscopic Treatment For Pancreaticobiliary Diseases

Preoperative Drainage for Malignant Biliary Strictures: Is It Time for Self-Expanding Metallic Stents?: Jason Roque, Shiaw-Hooi Ho, Khean-Lee Goh; Clin Endosc 2015;48(1):8-14. Published online January 31, 2015; DOI: https://doi.org/10.5946/ce.2015.48.1.8

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Palliation of jaundice improves the general health of the patient and, therefore, surgical outcomes. Because of the complexity and location of strictures, especially proximally, drainage has been accompanied by increased morbidity due to sepsis. Another concern is the provocation of an inflammatory and fibrotic reaction around the area of stent placement. Preoperative biliary drainage with self-expanding metallic stent (SEMS) insertion can be achieved via a percutaneous method or through endoscopic retrograde cholangiopancreatography. A recently published multicenter randomized Dutch study has shown increased morbidity with preoperative biliary drainage. A Cochrane meta-analysis has also shown a significantly increased complication rate with preoperative drainage. However, few of these studies have used a SEMS, which allows better biliary drainage. No randomized controlled trials have compared preoperative deployment of SEMS versus conventional plastic stents. The outcomes of biliary drainage also depend on the location of the obstruction, namely the difficulty with proximal compared to distal strictures. Pathophysiologically, palliation of jaundice will benefit all patients awaiting surgery. However, preoperative drainage often results in increased morbidity because of procedure-related sepsis. The use of SEMS may change the outcome of preoperative biliary drainage dramatically.

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Special Issue Article of IDEN 2013

Endoscopic Guided Biliary Drainage: How Can We Achieve Efficient Biliary Drainage?: Prashant Kedia, Monica Gaidhane, Michel Kahaleh; Clin Endosc 2013;46(5):543-551. Published online September 30, 2013; DOI: https://doi.org/10.5946/ce.2013.46.5.543

Abstract PDF PubReader ePub

Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

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Reviews

Technical Tips and Issues of Biliary Stenting, Focusing on Malignant Hilar Obstruction: Tae Hoon Lee; Clin Endosc 2013;46(3):260-266. Published online May 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.3.260

Abstract PDF PubReader ePub

Although there is no survival advantage, inoperable hilar cholangiocarcinoma managed by palliative drainage may benefit from symptomatic improvement. In general, biliary drainage is divided into endoscopic or percutaneous approaches and surgical drainage. Plastic or metal stent is the most preferred device for palliative drainage in endoscopic approach. Considering cost-effectiveness, use of metallic stent is preferred than plastic stents in patients with more than 3 months of life expectancy with inoperable malignant biliary obstruction. In patients with unresectable malignant hilar obstruction, the endoscopic approach with biliary stent placement by experts has been considered as the treatment of choice. However, the endoscopic management of hilar obstruction is often more challenging and complex than distal malignant biliary obstructions. There is still a lack of clear consensus on the use of plastic versus metal stents and unilateral versus bilateral drainage since the decision should be made under many grounds such as the volume of liver drainage more than 50%, life expectancy, and expertise of the facility.

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Endoscopic Stent Placement in the Palliation of Malignant Biliary Obstruction: Jin Hong Kim; Clin Endosc 2011;44(2):76-86. Published online December 31, 2011; DOI: https://doi.org/10.5946/ce.2011.44.2.76

Abstract PDF PubReader ePub

Biliary drainage with biliary stent placement is the treatment of choice for palliation in patients with malignant biliary obstruction caused by unresectable neoplasms. In such patients, the endoscopic approach can be initially used with percutaneous radiological intervention. In patients with unresectable malignant distal bile duct obstructions, endoscopic biliary drainage with biliary stent placement has now become the main and least invasive palliative modality, which has been proven to be more effective in >80% of cases with lower morbidity than surgery, and perhaps may provide a survival benefit. In patients with unresectable malignant hilar obstruction, the endoscopic approach for biliary drainage with biliary stent placement has also been considered as the treatment of choice. There is still a lack of clear consensus on the use of covered versus uncovered metal stents in malignant distal bile duct obstructions and plastic versus metal stents and unilateral versus bilateral drainage in malignant hilar obstructions.

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Endoscopic revision efficacy after clinically successful bilateral metal stenting for advanced malignant hilar obstruction
Tae Hoon Lee, Sung Ill Jang, Jong Ho Moon, Yun Nah Lee, Jae Kook Yang, Jin‐Seok Park, Seok Jeong, Don Haeng Lee, Nam Hun Heo, Sang‐Heum Park, Dong Ki Lee
Journal of Gastroenterology and Hepatology.2020; 35(12): 2248. CrossRef
Multidisciplinary Approach to Malignant Biliary Obstruction
Derek Taeyoung Kim, Uzma Rahman, Robert W. Tenney, Oleandro A. Cercio Roa, Pawan Rastogi, Jacob Cynamon, Yosef Golowa
Digestive Disease Interventions.2020;[Epub] CrossRef
Feasibility and efficacy evaluation of metallic biliary stents eluting gemcitabine and cisplatin for extrahepatic cholangiocarcinoma
Jing-Bo Xiao, Jun-Yong Weng, Yang-Yang Hu, Gui-Long Deng, Xin-Jian Wan
World Journal of Gastroenterology.2020; 26(31): 4589. CrossRef
Endoscopic palliation of biliary obstruction
A. Aziz Aadam, Kevin Liu
Journal of Surgical Oncology.2019; 120(1): 57. CrossRef
Biliary endoscopy in the management of primary sclerosing cholangitis and its complications
Brian M. Fung, James H. Tabibian
Liver Research.2019; 3(2): 106. CrossRef
Double plastic stenting for inoperable malignant biliary stricture among cirrhotic patients as a possible cost-effective treatment: a pilot study
Mohamed I. Radwan, Mohamed H. Emara, Mariam S. Zaghloul, Abdallah M.S. Zaghloul
European Journal of Gastroenterology & Hepatology.2019; 31(8): 1057. CrossRef
Prospective Multicenter Study of the Challenges Inherent in Using Large Cell-Type Stents for Bilateral Stent-in-Stent Placement in Patients with Inoperable Malignant Hilar Biliary Obstruction
Min Jae Yang, Jin Hong Kim, Jae Chul Hwang, Byung Moo Yoo, Sang Hyub Lee, Ji Kon Ryu, Yong-Tae Kim, Sang Myung Woo, Woo Jin Lee, Seok Jeong, Don Haeng Lee
Gut and Liver.2018; 12(6): 722. CrossRef
Multiple metallic stents placement for malignant hilar biliary obstruction: Perspective of a radiologist
Yozo Sato, Yoshitaka Inaba, Kazuo Hara, Hidekazu Yamaura, Mina Kato, Shinichi Murata, Yui Onoda
International Journal of Gastrointestinal Intervention.2016; 5(1): 52. CrossRef
Current Status of Biliary Metal Stents
Hyeong Seok Nam, Dae Hwan Kang
Clinical Endoscopy.2016; 49(2): 124. CrossRef
Radiofrequency ablation for pancreatobiliary disease
Alexander M. Sarkisian, Iman Andalib, Nikhil A. Kumta, Reem Z. Sharaiha
Current Opinion in Gastroenterology.2016; 32(5): 353. CrossRef
Endoscopic radiofrequency ablation may be preferable in the management of malignant biliary obstruction: A systematic review and meta‐analysis
Xiao Zheng, Zhi Yuan Bo, Wei Wan, Ye Chen Wu, Tian Tian Wang, Jun Wu, Dao Jian Gao, Bing Hu
Journal of Digestive Diseases.2016; 17(11): 716. CrossRef
Update on Pancreatobiliary Stents: Stent Placement in Advanced Hilar Tumors
Sung Ill Jang, Dong Ki Lee
Clinical Endoscopy.2015; 48(3): 201. CrossRef
Partially covered versus uncovered self-expandable nitinol stents with anti-migration properties for the palliation of malignant distal biliary obstruction: A randomized controlled trial
Min Jae Yang, Jin Hong Kim, Byung Moo Yoo, Jae Chul Hwang, Jun Hwan Yoo, Ki Seong Lee, Joon Koo Kang, Soon Sun Kim, Sun Gyo Lim, Sung Jae Shin, Jae Youn Cheong, Kee Myung Lee, Kwang Jae Lee, Sung Won Cho
Scandinavian Journal of Gastroenterology.2015; 50(12): 1490. CrossRef
Impact of Radiofrequency Ablation on Malignant Biliary Strictures: Results of a Collaborative Registry
Reem Z. Sharaiha, Amrita Sethi, Kristen R. Weaver, Tamas A. Gonda, Raj J. Shah, Norio Fukami, Prashant Kedia, Nikhil A. Kumta, Carlos M. Rondon Clavo, Michael D. Saunders, Jorge Cerecedo-Rodriguez, Paola Figueroa Barojas, Jessica L. Widmer, Monica Gaidhan
Digestive Diseases and Sciences.2015; 60(7): 2164. CrossRef
Recent Advances in Gastrointestinal Stent Development
Jin-Seok Park, Seok Jeong, Don Haeng Lee
Clinical Endoscopy.2015; 48(3): 209. CrossRef
A district general hospital experience of palliative biliary stenting
S E Thomas, M J Lee, N Sivaramakrishnan, K Lambert
BMJ Supportive & Palliative Care.2015; 5(3): 297. CrossRef
Paclitaxel-eluting nanofiber-covered self-expanding nonvascular stent for palliative chemotherapy of gastrointestinal cancer and its related stenosis
Se-Yoon Kim, Mina Kim, Min-kyoung Kim, Haneul Lee, Dong Ki Lee, Don-Haeng Lee, Su-Geun Yang
Biomedical Microdevices.2014; 16(6): 897. CrossRef
Feasibility of one‐step endoscopic metal stenting for distal malignant biliary obstruction
Shuya Shimizu, Itaru Naitoh, Takahiro Nakazawa, Kazuki Hayashi, Katsuyuki Miyabe, Hiromu Kondo, Michihiro Yoshida, Hiroaki Yamashita, Hirotaka Ohara, Takashi Joh
Journal of Hepato-Biliary-Pancreatic Sciences.2014; 21(3): 219. CrossRef
Bilateral Metallic Stenting in Malignant Hilar Obstruction
Tae Hoon Lee, Jong Ho Moon, Sang-Heum Park
Clinical Endoscopy.2014; 47(5): 440. CrossRef
Polymeric photosensitizer-embedded self-expanding metal stent for repeatable endoscopic photodynamic therapy of cholangiocarcinoma
Byoung-chan Bae, Su-Geun Yang, Seok Jeong, Don Haeng Lee, Kun Na, Joon Mee Kim, Guido Costamagna, Richard A. Kozarek, Hiroyuki Isayama, Jacques Deviere, Dong Wan Seo, D. Nageshwar Reddy
Biomaterials.2014; 35(30): 8487. CrossRef
Endobiliary radiofrequency ablation for malignant biliary obstruction
Halil Alis, Cetin Sengoz, Murat Gonenc, Mustafa Uygar Kalayci, Ali Kocatas
Hepatobiliary & Pancreatic Diseases International.2013; 12(4): 423. CrossRef
Technical Tips and Issues of Biliary Stenting, Focusing on Malignant Hilar Obstruction
Tae Hoon Lee
Clinical Endoscopy.2013; 46(3): 260. CrossRef
Otaru consensus on biliary stenting for unresectable distal malignant biliary obstruction
Atsushi Irisawa, Akio Katanuma, Takao Itoi
Digestive Endoscopy.2013; 25(S2): 52. CrossRef
Functional Self-Expandable Metal Stents in Biliary Obstruction
Chang-Il Kwon, Kwang Hyun Ko, Ki Baik Hahm, Dae Hwan Kang
Clinical Endoscopy.2013; 46(5): 515. CrossRef

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The Clinical Efficacy of Uisng a Soehendra Stent Retriever for Endoscopic Biliary Drainage in Malignant Biliary Obstruction: Pyo Jun Kim, M.D., Dae Hwan Kang, M.D., Hyung Wook Kim, M.D., Cheol Woong Choi, M.D., Ki Tae Yoon, M.D., Yong Wook Kim, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2009;39(5):271-275. Published online November 30, 2009

Abstract PDF: Background
/Aims: Endoscopic biliary drainage is widely used for the palliative treatment of malignant biliary obstruction. For the advanced stricture, the general treatments such as a dilating or balloon catheter can not fully expand a duct. The authors used a Soehendra Stent Retriever for these cases, and we evaluated the value of using this instrument for treating these patients.
Methods
From July 2006 to Jun 2008, we studied 12 patients with mailignant biliary obstruction (Klatskin's tumor=10, Gall bladder cancer=2) and who were failed at having a stent inserted with such general treatment such as using a dilating or balloon catheter (M：F=7：5, age=69.1 years old). For the bilateral biliary drainage of the duct, the "stent in stent" method was used and 12 patients were treated with a Soehendra Stent Retriever with clockwise rotation, as well as going forward to expand the target area of the intrahepatic bile duct obstruction and insert a metal stent.
Results
Ten patients among the 12 who were treated by a Soehendra Stent Retriever achieved successful insertion of a stent (technical success, 83.3%), and all 12 patients showed improvement of their jaundice.
Conclusions
To insert bilateral stents for the advanced malignant biliary obstruction, expanding the strictured area with a Soehendra Stent Retriever can improve the success of inserting a stent. (Korean J Gastrointest Endosc 2009; 39:271-275)

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Endoscopic Bilateral Metal Stent Placement with a Y-Configured Dual Stent for Advanced Hilar Carcinoma: Jong Ho Hwang, M.D.*, Dae Hwan Kang, M.D., Sang Yong Lee, M.D.*, Kyung Yeob Kim, M.D., Jae Sup Eum, M.D., Ji Young Kim, M.D., Do Hoon Kim, M.D., Gwang Ha Kim, M.D., Jeong Heo, M.D., Geun Am Song, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2008;36(1):7-13. Published online January 30, 2008

Abstract PDF: Background
/Aims: Palliative endoscopic or percutaneous internal drainage is widely used for treating hilar cholangiocarcinoma. Yet unilateral biliary drainage does not completely improve jaundice and it can induce acute cholangitis by the undrained contrast media. To investigate this technique's technical and clinical effectiveness, a newly devised Y-configured dual stent was used for treating advanced hilar malignancies. Methods: From May, 2005 to May, 2007, 20 hilar malignancies (men: women=9:11, age=70.5 yr) that were not suitable for surgical resection were included in this study. For bilateral metal stent placement, a biliary stent with a wide open central mesh was first inserted. After this, another stent without a hole was inserted into the contralateral hepatic duct through the open central mesh of the first stent. Results: Bilateral metal stent insertion was done in 14 of 20 patients. Among the 14 patients in whom bilateral stents were successfully placed, the rate of functional success was 100%. There were no early complications. As a late complication, stent occlusion occurred in 4 of 14 patients (28.5%), and one of these patients had a plastic stent inserted. The other 3 patients were treated with percutaneous transhepatic biliary drainage. The median stent patency period was 231 days. Conclusions: The bilateral metal stent method using the Y stent is safe and effective for bilateral biliary drainage in patients with unresectable hilar malignancies. (Korean J Gastrointest Endosc 2008;36:7-13)

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Bile Duct Cannulation Guided by a Percutaneous Transhepatic Biliary Drainage (PTBD) Tube: Modified Rendezvous Procedure: Hong Joo Kim, M.D., Seon Hyeong Choi, M.D.*, Jung Ho Park, M.D., Dong Il Park, M.D., Yong Kyun Cho, M.D., Chong Il Sohn, M.D., Woo Kyu Jeon, M.D. and Byung Ik Kim, M.D.; Korean J Gastrointest Endosc 2007;34(3):138-142. Published online March 30, 2007

Abstract PDF: Background
/Aims: To describe a simple and useful modification of the rendezvous technique using a PTBD tube as guidance. Methods: From January 2005 to August 2006, a total of 436 ERCPs were performed. A diagnosis of choledocholithiasis was made in 235 cases. Deep cannulation of the bile duct using standard techniques was unsuccessful in 27 patients (11.5%). A precut papillotomy led to successful cannulation in 16 out of these 27 patients (59.3%). The remaining 11 patients (40.7%) underwent PTBD with the tube tip placed in the second portion of the duodenum. Bile duct cannulation was attempted with the guidance of a PTBD tube in 9 cases. In the other 2 cases, the transduodenal approach was impossible due to a previous Billroth II operation. Results: Bile duct cannulation guided by a PTBD tube, which is also known as a modified rendezvous procedure, was successful in 9 out of 11 patients (81.8%). Deep cannulation of the bile duct was achieved in 100% of patients, who could be treated by endoscopy. There were 7 cases of transient hyperamylasemia (77.8%) but no procedure-related major complications or mortality. Conclusions: Bile duct cannulation guided by a PTBD tube in patients with choledocholithiasis can be recommended when ERCP is unsuccessful using the standard technique. (Korean J Gastrointest Endosc 2007;34:138⁣142)

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The Clinical Efficacy of Percutaneous Bilateral Internal Drainage in Advanced Hilar Malignancy by T-Configured Dual Stent Placement: Comparison with Unilateral Endoscopic Stent Placement: Joo Ho Lee, M.D., Sang Yong Lee, M.D., Jung Hyun Lee, M.D., Hyo Jin Jung, M.D., Tae Oh Kim, M.D., Gwang Ha Kim, M.D., Jeong Heo, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D., Mong Cho, M.D., Suk Kim, M.D.*, Chang Won Kim, M.D.* and Suk Hong Lee, M.D.*; Korean J Gastrointest Endosc 2006;33(2):85-93. Published online August 30, 2006

Abstract PDF: Background
/Aims: Endoscopic or percutaneous internal drainage is a well-established palliative treatment for unresectable biliary tumors. Previous studies dealing with the unilateral versus bilateral liver lobe drainage have reported inconsistent results. This study evaluated the clinical efficacy of bilateral drainage with a newly designed T configured dual stent (T-stent) placement. Methods: From 2001 to 2004, 46 hilar malignancies, which were not suitable for endoscopic retrograde biliary drainage (ERBD) on MR cholangiography were treated with the percutaneous placement of two self-expandable metallic endoprostheses in a T configuration through a single transhepatic access. The outcomes were examined retrospectively. The hilar malignancies, which were drained by unilateral ERBD were also reviewed. Results: The 46 hilar malignancies drained by a T stent included a cholangiocarcinoma (n=36), gallbladder cancer (n=6), and metastatic cancer (n=4). Procedure related cholangitis occurred in 3 out of 46 patients (6.5%). The mean survival and stent patency times were 256 and 194 days, respectively. The 34 hilar malignancies drained by unilateral ERBD included cholangiocarcinoma (n=29), gallbladder cancer (n=3), and pancreatic cancer (n=2). Procedure related cholangitis occurred in 7 out of 34 patients (20.6%). The mean survival and stent patency times were 292 and 186 days, respectively. There were no statistically significant differences in the cholangitis frequency, survival and stent patency between the two groups. The frequency of cholangitis, mean survival and patency time in Klatskin tumors, which were drained by the T-stent (n=36) and ERBD (n=29), were compared. There were no significant differences in survival and stent patency time. Conclusions: T-configured dual stent placement can be used effectively in advanced biliary hilar malignancies. It can be used as a safe palliative drainage method in advanced hilar tumors, which are not suitable for ERBD. (Korean J Gastrointest Endosc 2006;33:85⁣93)

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Analysis of Factors Influencing the Long Term Outcome after Endoscopic Stenting for Benign Biliary Stricture: Seok Young Lee, M.D., Hyung Suk Lee, M.D., Won Jae Yoon, M.D., Jun Kyu Lee, M.D., Kwang Hyuck Lee, M.D., Jin-Hyeok Hwang, M.D.*, Ji Bong Jeong, M.D.^†, Ji Kon Ryu, M.D., Yong-Tae Kim, M.D. and Yong Bum Yoon, M.D.; Korean J Gastrointest Endosc 2006;32(1):21-26. Published online January 30, 2006

Abstract PDF: Background
/Aims: The problem with endoscopic management for benign biliary stricture is the occurrence of restenosis after removal of biliary stents. However the factors that influence the rate of restenosis have not yet been identified. The aim of this study was to identify the factors that affect patency of the bile duct after removal of an endoscopic stent for management of benign biliary stricture. Methods: The medical records and potential factors that influence biliary restenosis were analyzed in 19 patients with benign biliary stricture. Results: At the time of stent removal, successful stricture resolution was noted in 13 out of 19 patients. Among these 13 patients, good biliary patency, without restenosis, was observed in 10 patients during a mean follow-up of 24 months. The time interval, from biliary surgery to stricture, tended to be shorter in the group with good results compared to the group with poor results (6.2±3.3 months vs. 80.2±139.3 months respectively: p=0.07). Other factors did not affect the rate of restenosis after removal of the stent. Conclusions: The time interval, from biliary surgery to stricture, tends to influence restenosis after endoscopic management for benign biliary stricture. (Korean J Gastrointest Endosc 2006;32:21⁣26)

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Efficacy of Percutaneous Cholangioscopic Ethanol Injection in Hepatocellular Carcinoma Invading the Bile Duct: Jung Min Choi, M.D., Sung Koo Lee, M.D., Sang Soo Lee, M.D., Jang Han Lee, M.D., Moon Hee Song, M.D., Dae Keun Pyun, M.D., Tae Jun Song, M.D., Jung Sik Choi, M.D., Do Hyun Park, M.D., Dong Wan Seo, M.D., Myung Hwan Kim, M.D. and Young Il Min, M.D.; Korean J Gastrointest Endosc 2005;30(6):305-311. Published online June 30, 2005

Abstract PDF: Background
/Aims: To evaluate the clinical outcomes of the percutaneous cholangioscopic ethanol injection in the hepatocellular carcinoma (HCC) invading the bile duct, we conducted a retrospective study. Methods: Ten patients who received the percutaneous cholangioscopic ethanol injection were selected patients were diagnosed as HCC invading the bile duct between January 1998 and February 2004. Treatment response, complications, survival or death and survival time were analyzed. Results: Ten patients received mean of 5.3 sessions (range 2∼19) of cholangioscopic ethanol injection. Eight patients had decreased tumor mass, and the rest 2 patients had no response. Complications were pain (n=10), hemobilia (n=6: bleeding was minimal), cholangitis (n=2), bile duct rupture (n=1), and bile duct stricture (n=1). Nine patients died from severe hepatic failure and sepsis, one patient has survived for 19 months as of now. Median survival time was 5 months (range 2∼19 months). Percutaneous transhepatic biliary drainage (PTBD) could be removed in two patients. Conclusions: Percutaneous cholangioscopic ethanol injection in HCC invading the bile duct showed size reduction of mass. PTBD could be no longer needed in some patients. However, supportive cares such as PTBD may be appropriate considering their short survival period and risk of procedure. (Korean J Gastrointest Endosc 2005;30: 305⁣311)

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A Case of Sigmoid Colonic Perforation due to Migration of a Plastic Stent for Endoscopic Retrograde Biliary Drainage: Hyun Sweung Jeong, M.D., Sang Jong Park, M.D., IL Dong Kim, M.D.*, Sang Bae Lee, M.D., Jin Kwang Lee, M.D. and Hoi Jin Kim, M.D.; Korean J Gastrointest Endosc 2004;28(3):156-160. Published online March 31, 2004

Abstract PDF: Placement of an endoprosthesis for billiary obstruction has been advocated as an effective alternative for internal- external drainage catheters or surgical procedure. Endoscopic retrograde biliary drainage (ERBD) is a method of transpapillary insertion and placement of drainage tube in the billiary tree under the direct view of endoscope. Early complications following ERBD that develop within 4 weeks include obstruction of the stent, cholangitis, hemorrhage, acute pancreatitis, and bile duct or duodenal perforation. Late complications include obstruction of the stent and cholangitis, migration of the stent, and intestinal perforation. We expierenced a case of sigmoid colonic perforation following ERBD in a patient with multiple biliary tract stone and cholangitis. Thus we report this case with a brief review of the literature. (Korean J Gastrointest Endosc 2004;28:156⁣160)

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Endoscopic Biliary Drainage Using Soehendra Stent: Joo Ho Lee, M.D., Cheul Woong Choi, M.D., Sang Yong Lee, M.D., Jin Ouk Kang, M.D.,; Korean J Gastrointest Endosc 2003;26(1):15-20. Published online January 30, 2003

Abstract PDF: Background
/Aims: Endoscopic biliary drainage (EBD) has been used effectively as the palliative treatment for malignant biliary obstruction. In high grade strictures, endoscopic stenting can be achieved by dilating devices such as dilating or balloon catheters. Subgroup of malignant biliary obstructions are too stenotic to allow passage of plastic or metal stents. In cases of failure of conventional stenting, we evaluated the efficacy and safety of the 7-Fr Soehendra stent retriever (SSR) used as a dilator. Methods: From January 1999 to September 2001, 14 patients with malignant pancreaticobiliary stirictures (2 pancreatic, 12 biliary) that could not be traversed with plastic or metal stents, underwent stricture dilation with SSR. An endoscopic sphincterotomy was performed and a guide wire was inserted beyond the stricture. Then the SSR was introduced over the guide wire via duodenoscope. Then the stricture was traversed by torquing the SSR clockwise while pushing it. The SSR was removed and then the plastic or metal stents were inserted above the stricture. Results: Of the 14 patients, 13 patients (93%) underwent successful stenting using SSR. Symptom relief was observed in all patients after endoscopic biliary stenting. One patient (7%) went on to percutaneous biliary drainage because we failed to insert the metal stent into the stenotic left hepatic duct after traversing the stricture with SSR. There were no significant complications such as bile duct or duodenal perforation and bleeding. Conclusions: The Soehendra stent retriever is useful and safe for dilation with subsequent stent placement of malignant pancreaticobiliary stirictures resistant to conventional stenting. However, this device may be difficult to pass a tortuous or small-diameter hilar stricture. (Korean J Gastrointest Endosc 2003;26:15⁣20)

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Three Case of Acute Pancreatitis Complicating Endoscopic Insertion of the Biliary Stent: Sung Gwon Kim, M.D., Jong Jae Park, M.D., Moon Gi Chung, M.D., Oh Sang Kwon, M.D.,Dong Kyun Park, M.D., Yang Suh Koo, M.D., Sun Suk Kim, M.D., You Kyung Kim, M.D.,Dong Hoon Kang, M.D., Duck Joo Choi, M.D., Hyun Chul Park, M.D. and Ju Hyun Kim, M.D.; Korean J Gastrointest Endosc 2001;22(4):233-238. Published online April 30, 2001

Abstract PDF: Acute pancreatitis is one of the major complications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST). Various etiology such as mechanical, chemical, hydrostatic, and thermal factor are thought to be involved for this procedure-related pancreatitis. However, acute pancreatitis can occur as a direct complication of endoscopic biliary drainage (EBD). Although the exact mechanism remains unclear, it is postulated that the stent compresses pancreatic ductal orifice and resultant pancreatic outflow obstruction actually provokes pancreatitis. Using the larger stent diameter over 10 Fr and a straight stent rather than curved one, proximal rather than distal bile duct obstruction are risk factors for stent-induced pancreatitis. We report on three cases of acute pancreatitis complicating the EBD with a plastic stent, nasobiliary catheter, and covered-metallic stent respectively. (Korean J Gastrointest Endosc 2001;22:233⁣238)

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일반적인 내시경적 담도배액법이 어려운 경우에 Soehendra Stent Retriever 을 이용한 담도배액법: Korean J Gastrointest Endosc 2001;23(5):326-326. Published online November 30, 2000

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유두부암 환자에서 내시경적 담관 십이지장 누공 형성술의 임상적 유용성 ( Clinical Usefulness of Endoscopic Choledochoduochoduodenal Fistulotomy in Patients with Ampullary Cancer ): Korean J Gastrointest Endosc 2000;21(1):525-533. Published online November 30, 1999

Abstract PDF: Backgorund/Aims : Endoscopic choledochoduodenal fistulotomy(fistulotomy), using a needle-knife sphin-cterotome as an alternative to failed duct cannulation and subsequent endoscopic drainage in patients with ampullary cancer, can be performed in patients with a suprapapillary bulged or distorted papilla. The purpose of this prospective sutdy was to evaluate the safety and clinical usefulness of endoscopic fistulotomy in patients with ampullary cancer. Methods : Of the 29 patients with ampullary cancer requiring biliary drainage, 13 patients with a suprapapillary bulged papilla underwent fistulotomy either alone or followed by an upward extension of the fistulous orifice using a standard sphincterotome (fistulotomy group). Of the remaing 16 patients, transpapillary biliary stenting was successful in 13 patients (biliary stenting group). In both group, the rate of successful bile duct cannulation and effective biliary drainage were assessed and compared. Results : Bile duct cannulation was successful in 92.3% of the patients in the fistulotomy group and 81.3% of patients in the biliary stenting group, and the only complications were mild bleeding in 1 patient (7.7%) and cholangitis in 1 patient(6.3%). The success rate for initial biliary drainage with the fistulotomy or transpapillary stenting were 100% and 84.6%, respectively. Of the 12 patients in whom biliary drainage was used as the definite treatment, the symptom-free duration was 3.2 months in 6 patients of the fistulotomy group and 3.9 months in 6 patients in the biliary stenting group. Conclusions : Endoscopic fistulotomy is safe and effective for both preoperative and palliative biliary decompression in patients with ampullary cancer and it is suggested that the procedure can be applied primarily to increase the success rate of biliary access and subsequent biliary drainage especially in patients with a bulged papilla. (Korean J Gastrointest Endosc 2000;21:525-533)

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경피경간 담도배액관을 따라 피부로 전이된 담도암 1예 ( Subcutaneous Implantation Metastasis of a Cholangiocarcinoma of the Bile Duct after Percutaneous Transhepatic Biliary Drainage (PTBD) ): Korean J Gastrointest Endosc 1999;19(5):837-842. Published online November 30, 1998

Abstract PDF: Percutaneous transhepatic biliary catheterization (PTC) has not only been increasingly used in the localization of benign and malignant lesions, but it is also considered rapid, safe and effective method to establish internal and external drainage for decompression of biliary obstructions. Infections and granulomas at the catheter entry site can occasionally develop, but are easily managed. However, such technique, when used both for obtaining malignant cells for diagnosis and for percutaneous decompression of the biliary tract can exposure the patient at risk for dissemination of the tumor along the catheter tract. This rare complication has been observed in a patient who underwent percutaneous transhepatic biliary drainage (PTBD) for malignant biliary tract obstruction. Although tumor cell seeding along the catheter tract is a very rare complication, we think that PTBD should be avoided when curative resection is planned. (Korean J Gastrointest Endosc 19: 837∼842, 1999)

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