title: Endoscopic ultrasound-guided antegrade treatments for biliary disorders in patients with surgically altered anatomy.
abstract: BACKGROUND
  Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy is challenging. Several endoscopic ultrasound (EUS)-guided biliary access techniques have been reported as effective alternatives. EUS-guided antegrade treatments (AG) have been developed more recently but have not yet been studied well.
  
  
  OBJECTIVE
  To evaluate the feasibility and safety of EUS-AG for biliary disorders in patients with surgically altered anatomies.
  
  
  METHODS
  We retrospectively identified all the patients who underwent EUS-AG. The left intrahepatic bile duct (IHBD) was initially punctured from the intestine followed by cholangiography, antegrade guidewire manipulation, and bougie dilation of the fistula. Either antegrade biliary stenting (ABS) or antegrade balloon dilation (ABD) was performed depending on the biliary disorders. In stone cases, the stones were antegradely pushed out using a balloon. After ABD, a nasobiliary drainage tube was placed to prevent possible bile leak and to keep an access route for any possible repeat procedures.
  
  
  RESULTS
  EUS-AG was attempted in seven patients including choledocholithiasis in five, malignant biliary obstruction in one, and bilioenteric anastomosis stricture in one. EUS-AG was not performed in one patient because EUS-cholangiography did not indicate the presence of stones. In the remaining six patients, the IHBD was successfully punctured, followed by cholangiography, guidewire insertion, and bougie dilation. ABS and ABD were successfully performed in one and five patients, respectively. Antegrade procedures with ABD were repeated twice in one patient. Mild complications were observed in two patients.
  
  
  CONCLUSIONS
  EUS-AG for biliary disorders in patients with surgically altered anatomy is feasible. Further studies are warranted.
authors.affiliation: First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.
authors.forename: Takuji
authors.initials: T
authors.lastname: Iwashita
authors.forename: Ichiro
authors.initials: I
authors.lastname: Yasuda
authors.forename: Shinpei
authors.initials: S
authors.lastname: Doi
authors.forename: Shinya
authors.initials: S
authors.lastname: Uemura
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Mabuchi
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Okuno
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Mukai
authors.forename: Takao
authors.initials: T
authors.lastname: Itoi
authors.forename: Hisataka
authors.initials: H
authors.lastname: Moriwaki
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001660:Biliary Tract Diseases / Q000601:surgery*; D001662:Biliary Tract Surgical Procedures / Q000379:methods*; D016145:Endoscopy, Digestive System / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged
references.citation: Endoscopy. 2012 Jan;44(1):60-5
references.pmid: 22127960
references.citation: Gastrointest Endosc Clin N Am. 2012 Apr;22(2):249-58, viii-ix
references.pmid: 22632947
references.citation: Endoscopy. 2008 Apr;40(4):340-2
references.pmid: 18389451
references.citation: Dig Dis Sci. 2012 May;57(5):1391-8
references.pmid: 22198702
references.citation: Gastrointest Endosc. 2011 Dec;74(6):1276-84
references.pmid: 21963067
references.citation: Gastrointest Endosc Clin N Am. 2012 Apr;22(2):271-80, ix
references.pmid: 22632949
references.citation: Endoscopy. 2009 Jun;41(6):532-8
references.pmid: 19533558
references.citation: Z Gastroenterol. 2002 Jul;40(7):503-10
references.pmid: 12122598
references.citation: Endoscopy. 2010 Aug;42(8):656-60
references.pmid: 20589594
references.citation: Gastrointest Endosc. 2012 Feb;75(2):354-9
references.pmid: 22248603
references.citation: Gastrointest Endosc. 2010 Feb;71(2):413-9
references.pmid: 20152319
references.citation: Surg Endosc. 2011 Mar;25(3):713-21
references.pmid: 20976503
references.citation: Am J Gastroenterol. 2011 Jul;106(7):1239-45
references.pmid: 21448148
references.citation: AJR Am J Roentgenol. 2010 Oct;195(4):851-7
references.pmid: 20858809
references.citation: Endoscopy. 2011 Dec;43(12):1105-8
references.pmid: 22057823
references.citation: Gastrointest Endosc. 2005 Jan;61(1):112-25
references.pmid: 15672074
references.citation: Gastrointest Endosc. 2012 Mar;75(3):692-3
references.pmid: 21679943
references.citation: JOP. 2011 Nov 09;12(6):610-3
references.pmid: 22072253
references.citation: Endoscopy. 2010 Jun;42(6):496-502
references.pmid: 20419625
references.citation: Eur J Gastroenterol Hepatol. 1999 Jul;11(7):775-80
references.pmid: 10445799
references.citation: Gastrointest Endosc. 2006 Oct;64(4):663-7
references.pmid: 16996372
references.citation: Gastrointest Endosc. 2010 Mar;71(3):446-54
references.pmid: 20189503
references.citation: World J Gastroenterol. 2008 Oct 21;14(39):6078-82
references.pmid: 18932289
references.citation: Endoscopy. 2007 Apr;39(4):287-91
references.pmid: 17357952
references.citation: Endoscopy. 2010 Mar;42(3):232-6
references.pmid: 20119894
references.citation: Dig Endosc. 2010 Apr;22(2):147-50
references.pmid: 20447212
references.citation: Endoscopy. 2008 Apr;40(4):336-9
references.pmid: 18264890