The 7th Joint Session between JDDW-KDDW-TDDW3(JDDW)
Thu. November 2nd   9:00 - 12:00   Room 10: Portopia Hotel Waraku
Clinical outcomes of EUS-guided antegrade stone removal for common bile duct stones in patients with surgically altered anatomy
Shuntaro Mukai1, Takayoshi Tsuchiya1, Takao Itoi1
1Department of Gastroenterology and Hepatology, Tokyo Medical University
Background and Aims: Although balloon enteroscopy-assisted ERCP (BE-ERCP) is an effective and safe treatment technique for common bile duct (CBD) stones in patients with surgically altered anatomy (SAA), BE-ERCP is not always successful. Recently, EUS- guided antegrade stone removal (EUS-ASR) by using a 1-step or 2-step procedure has been developed for BE-ERCP failure cases. The aim of this study was to evaluate the clinical outcomes of EUS-ASR for CBD stones in patients with SAA.
Methods: In 29 of 217 patients [14.4%, mean 79 years old, post total or distal gastrectomy with Roux-en-Y reconstruction (n=27), post distal gastrectomy with Billroth-II reconstruction (n=2)] in whom BE-ERCP failed, EUS-ASR was attempted for difficult CBD stones from January 2014 to December 2022.
Results: The overall technical success of the creation of the hepatoenteric tract was 96.6% (28/29, HGS/HJS=13/15). The mean diameter of punctured bile duct was 2.8mm (1.5-4.7). 19-gauge puncture needle was used in 8 cases and 22-gauge in 20 cases(two-step puncture technique was required in 3 cases). In one failure case, it was difficult to puncture the non-dilated bile duct. Adverse events were observed in only one case(3.6%,1/28, bleeding at the puncture line). Regarding stone removal, 1-stage EUS-ASR was performed in 10 cases(mean stone size 7mm)and complete stone removal was succeeded in all cases with mean 23 minutes procedure time. In another 18 cases (mean stone size 13mm), 2-stage EUS-ASR was performed mean 51 days after EUS-HGS/HJS. In 14 cases complete antegrade stone removal was succeeded and in 3 cases stone removal was succeeded by antegrade rendezvous technique and BE-ERCP with low adverse event rate 5.6%(1/18, cholangitis 1). The final clinical success rate of EUS-ASR was 93.1% (27/29, intention to treat analysis). After EUS-ASR in 26 cases the stent placed at the hepatoenteric tract was removed finally and stent-free was achieved. In one case, the fistula was kept due to the patient's desire.
Conclusions: 1-step or 2-step EUS-ASR depending to the situation of CBD stones in patients with SAA appears to be an effective and safe alternative procedure after BE-ERCP failure.
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