Endosonography-guided biliary drainage is useful in cases with failed endoscopic biliary stenting

Nov 5 2007

The role of endosonography (ES) in digestive diseases is expanding gradually from diagnostic applications to therapeutic ones. The feasibility of ES-guided cholangiopancreatography was first reported by Harada et al. (pancreatography) and Wiersema et al. (cholangiography) in 1995 and 1996, respectively.

Several reports on the application of ESBD for a therapeutic purpose have been published since 2001. However, there have been no reports as to the influence of this technique on the gut wall, the bile duct, and the intervening tissues. A research article published on November 7 issue 41 of World Journal of Gastroenterology addresses one answer to this question in a case report form.

Dr. Fujita and his colleagues from Sendai City Medical Center applied ESBD via the duodenum for decompression of the biliary tree, in a patient with cancer of the papilla of Vater complaining of itching and jaundice, and reported the results of histological evaluation on and around the sinus tract created by ESBD. The patient underwent pancreaticoduodenectomy 14 days after ESBD. Macroscopically, the sites of puncture in the bile duct and the duodenum were clear without infection, hemorrhage, or hematoma. Histological examination revealed mild inflammatory cell infiltrate adjacent to the sinus tract in the duodenal wall and the bile duct wall without hemorrhage. A fistula was formed along the tract of the puncture without significant reactive changes. This is the first report describing the histological condition of the sinus tract established by this method.

They concluded these results were attributable to the use of endosonography as a guide, resulting in a low potential risk of major bleeding as color Doppler evaluation was utilized for determination of the route of puncture. Injury of adjacent organs was also minimized due to clear visualization of the structures in the area of interest. The method of choice for biliary obstruction is, in general, endoscopic biliary stenting. At present, percutaneous transhepatic cholangio-drainage (PTCD) is considered to be a substitute. PTCD, however, is followed by pain after placement of a drainage tube and restricts patients' daily living. On the contrary, ESBD is a safe and effective method of biliary drainage without pain or restriction in daily living, as in endoscopic biliary stenting, and will therefore replace PTCD in a large proportion of patients having an obstructed biliary tree with difficult cannulation of the bile duct, duodenal stenosis, and deformity of the papilla by cancer, which hinder detection of the orifice, regardless of the likelihood of successful PTCD.

The research team also predict further development of accessory devices specialized for ESBD will expand its indications. ESBD may replace PTCD, or even EBS, in selected patients, although further comparative study is needed.

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