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Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure used to treat malignant biliary obstruction. However, complications such as duodenal obstruction and surgically altered anatomy can lead to the failure of ERCP. In such cases, percutaneous transhepatic biliary drainage (PTBD) has been used as an alternative, but it comes with a high rate of adverse events (AEs). Recently, Endoscopic ultrasound-guided biliary drainage (EUS-BD) has gained popularity over PTBD, with endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) being described as an effective technique.
While EUS-HGS has shown a high success rate, the occurrence of bile leakage remains a concern, with an incidence ranging from 2.8% to 11%. Bile leakage can be a fatal complication, highlighting the importance of finding ways to reduce it. Recent studies have shown that bile aspiration after inserting an ERCP contrast catheter can help reduce the risk of bile leakage. However, the optimal type of catheter for EUS-HGS remains unknown.
A novel ERCP contrast catheter with a tapered 3.3-French (Fr) tip has been developed, which may aid in smooth insertion during the procedure. This study aimed to compare the conventional ERCP contrast catheter with the novel one and evaluate its efficacy and safety in EUS-HGS procedures.
Methods
1. Ethics Statements
The study was approved by the local institutional review board and conducted in accordance with the Declaration of Helsinki.
2. Study Design and Population
The study retrospectively analyzed patients who underwent EUS-HGS between January 2021 and August 2023 at four institutions. Patients who met specific exclusion criteria were not included in the analysis. The novel tapered ERCP contrast catheter (SHOREN) was used in this study, along with a conventional ERCP contrast catheter for comparison.
3. EUS-HGS
Experienced endoscopists performed all EUS-HGS procedures using a conventional curved linear array echoendoscope. The bile duct puncture, guidewire insertion, and stent deployment were carried out according to standard protocols, with the type of ERCP contrast catheter chosen by the endoscopist.
4. Outcome Measurements
The study compared the success rate of ERCP contrast catheter insertion, insertion guidewire angle, technical success rate, procedure time, and adverse events between the conventional and novel catheter groups. Successful insertion in a single attempt, insertion angle, overall technical success, procedure time, and AEs were recorded and compared between the two groups.
Overall, the study aimed to assess the efficacy and safety of the novel tapered ERCP contrast catheter in EUS-HGS procedures and its potential to reduce bile leakage and improve patient outcomes.
Novel ERCP Catheter Improves Outcomes of EUS-HGS Procedures
Following a recent study, fever was defined as a temperature of over 38°C persisting for 24 hours after the EUS-HGS procedure. Additionally, abdominal pain was described as new-onset abdominal pain that worsened after the EUS-HGS procedure.
The study compared the outcomes of EUS-HGS using a conventional ERCP contrast catheter with those of a novel ERCP contrast catheter. The novel catheter, equipped with a 3.3-Fr tapered tip, facilitated easier insertion into the intrahepatic bile duct during EUS-HGS, marking it as the first study to evaluate the efficacy of this innovative tool.
One of the critical factors in preventing adverse events during EUS-HGS is bile peritonitis, which can be fatal. To address this, methods such as one-step EUS-HGS have been introduced, aiming to reduce bile leakage. However, the deployment of a stent outside the bile duct poses a risk due to difficulties in confirming the bile duct without sufficient contrast medium injection. In such cases, the use of ERCP contrast catheters becomes crucial for steady detection of the bile duct with contrast media.
The novel ERCP catheter, featuring a more tapered tip than its conventional counterpart, enhances smooth insertion into the bile duct. The success rates of ERCP catheter insertion in a single attempt were significantly higher in the novel group compared to the conventional group, indicating its superior ease of insertion.
While previous reports have recommended performing EUS-HGS in tertiary care and experienced centers, the study revealed that endoscopists with extensive experience in EUS-HGS procedures achieved higher success rates with the novel ERCP catheter. This suggests that the novel catheter may be particularly beneficial for trainee endoscopists or those performing the procedure in general hospital settings.
Although the study did not show significant differences in the overall complication rates between the two groups, further investigation is needed to evaluate the effectiveness of the novel ERCP catheter in larger populations. The wider lumen of the novel catheter may play a crucial role in reducing bile leakage, as bile aspiration has been identified as an effective method for preventing adverse events.
In conclusion, the novel ERCP catheter demonstrates advantages in smooth insertion due to its tapered tip, making it suitable for EUS intervention procedures. Large-scale studies are necessary to determine the most effective and safest treatment approaches for EUS-HGS using the novel ERCP catheter.
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