Strategy of biliary drainage in patients with surgically altered anatomy

Background: Biliary drainage in patients with surgically altered anatomy (SAA) has been performed mainly by percutaneous transhepatic or surgical procedures. However, with the recent development of balloon-assisted endoscopy (BAE) and endoscopic ultrasound-guided biliary drainage (EUS-BD), endoscopic approaches have been attempted as first-line approaches.
Objective: To evaluate the outcomes of endoscopic biliary drainage in patients with SAA.
Methods: A retrospective analysis was conducted in patients with SAA who underwent endoscopic biliary drainage at our institution between April 2018 and March 2024. We assessed their backgrounds and treatment outcomes.
Results: A total of 100 patients were included in this study (median age: 74 years). Previous surgical methods included hepaticojejunal anastomosis (n=13), pancreatoduodenectomy (n=40), Roux-en-Y reconstruction (n=33), Billroth-II (n=11), and total pancreatectomy (n=3). As the initial approach, endoscopic access to the papilla or bilio-enteric anastomotic site using BAE/EGD/colonoscopy was successful in 90% of the patients. The successful biliary cannulation rate was 80%, and the procedure completion rate was 74%. The procedure-related adverse events included enteric perforation in 4 cases and bleeding in 2 cases. After the failed initial approach, EUS-BD (n=8) and PTBD (n=11) were attempted and were successful in all cases, but one case developed mediastinitis after EUS-BD.
Conclusion: Endoscopic biliary drainage using BAE/EGD/colonoscopy in patients with SAA can be accepted as a first-line approach. EUS-BD or PTBD are also effective rescue options in failed cases.