EUS-guided antegrade metal stenting with hepaticoenterostomy using a dedicated plastic stent with a review of the literature (with video)

BACKGROUND AND OBJECTIVES: Recently, a novel EUS-guided biliary drainage (EUS-BD) technique consisting of EUS-guided antegrade stenting and EUS-guided hepaticoenterostomy (EUS-AS+HES) using two conventional metal stents (MS) has been reported to decrease adverse events and maintain longer stent patency for malignant biliary obstruction (MBO). However, only a few limited reports have evaluated this technique. Finally, dedicated plastic stents (PSs) have been developed to perform EUS-HES safely. The aim of the present study was to evaluate the outcome in EUS-AS+HES for MBO using the dedicated HES PSs. METHODS: The results of a total of 23 patients who underwent EUS-AS+HES (18 simultaneous cases and 5 sequential cases) for MBO from October 2014 to July 2017 were retrospectively reviewed. RESULTS: Technical and clinical success rates were 100% (23/23). Adverse events were seen in 8.7% (2/23); 2 cases of mild biliary peritonitis, which were successfully managed conservatively. Overall survival was 96 days and the median duration of stent patency, including stent dysfunction, patient death, and last follow-up, was 66.0 days (53 days in simultaneous cases and 78 days in sequential cases). Stent dysfunction was seen in 13.0% (3/23) of patients in 267, 263, and 135 days after the procedure. CONCLUSIONS: The novel EUS-BD technique, EUS-AS using MS plus HES employing a dedicated PS, was shown to be a feasible procedure for MBO and should yield longer duration of stent patency. Furthermore, sequential antegrade stenting in cases of occluded HES seems to be one other option instead of HES stent exchange. Further large-scale comparison studies with EUS-HES or EUS-AS are required to confirm its clinical efficacy.