Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

Evaluation of the change in liver stiffness after biliary drainage in patients with extrahepatic cholestasis

Increased liver stiffness (LS) due to extrahepatic cholestasis has been reported to reduce after biliary drainage. As far as we know, it has not been evaluated whether the method of drainage makes a difference in the change in liver stiffness until now. The aim of the study was to answer this question. The patients planned for endoscopic biliary drainage (EBD) or percutaneous biliary drainage (PBD) were enrolled for over an 18-months’ time period. In those without chronic liver disease or liver tumor, liver stiffness was measured before and 10 days after the intervention, using acoustic radiation force impulse (ARFI) elastography. A total of 30 patients were included in the study excluding the ones not fulfilling the criteria and were divided into two groups: EBD group (n = 15) and PBD group (n = 15). The measurements were above the cut-off value for severe fibrosis (1.55 m/s) in all patients with a mean of 2.50 ± 0.72 m/s before drainage. The pre-drainage values of the PBD group were significantly higher than of the EBD group (2.79 ± 0.58 m/s vs 2.22 ± 0.74 m/s, p = 0.02). In all patients except 11, a significant reduction was observed in the stiffness values. The reduction with PBD was more significant than with EBD (p = 0.04). Percutaneous biliary drainage provided a more significant reduction in liver stiffness in patients with extrahepatic cholestasis. However, this result appears to be related to the nature of obstruction rather than the method of drainage, making the comparison weaker than expected from the original design.

Permanent External Biliary Catheter: A Difficult Problem Managed by Rescue Technique of Hepaticocholecystogastrostomy

Percutaneous biliary drainage is commonly performed procedure after failure of ERCP in patients with biliary obstruction. Failure to internalization can lead to permanent external catheter. In the present case, problem of external biliary catheter was solved with hepaticocholecystogastrostomy. Guidewire from the external drain site could not be passed across the stricture, instead it was entering in the gall bladder. This was used as an opportunity to internalize the catheter. First EUS guided cholecystogastrostomy was performed, followed by placement of stent between right biliary system and the stomach, through the cholecystogastrostomy stent. This led to drainage of right biliary system into the stomach, and the external catheter could be removed.