Infectious peritonitis after endoscopic ultrasound-guided biliary drainage in a patient with ascites

SUMMARY OF EVENT: Bacterial, mycotic peritonitis and Candida fungemia developed in a patient with moderate ascites who had undergone endoscopic ultrasound-guided biliary drainage (EUS-BD). Antibiotics and antifungal agent were administered and ascites drainage was performed. Although the infection improved, the patient's general condition gradually deteriorated due to aggravation of the primary cancer and he died. TEACHING POINT: This is the first report to describe infectious peritonitis after EUS-BD. Ascites carries the potential risk of severe complications. As such, in patients with ascites, endoscopic retrograde cholangiopancreatography (ERCP) is typically preferred over EUS-BD or percutaneous drainage to prevent bile leakage. However, ERCP may not be possible in some patients with tumor invasion of the duodenum or with surgically altered anatomy. Thus, in patients with ascites who require EUS-BD, we recommend inserting the drainage tube percutaneously and draining the ascites before and after the intervention in order to prevent severe infection.

Risks of transesophageal endoscopic ultrasonography-guided biliary drainage

SUMMARY OF EVENT: Pneumoderma, mediastinal emphysema, and bilateral pneumothorax were developed in the patient who had undergone transesophageal endoscopic ultrasonography-guided rendezvous technique. Chest drainage was performed immediately. TEACHING POINT: Transesophageal approach carries the potential risks of severe complications such as mediastinal emphysema, mediastinitis, and pneumothorax. To prevent puncturing through the esophagus, clipping the esophagogastric junction using a forward-viewing scope before procedure is very useful. In cases of inadvertent transesophageal puncture, devices other than the needle should not be passed through the site.

EUS-Guided Biliary Drainage

Endoscopic ultrasonography (EUS) combines endoscopy and intraluminal ultrasonography, and allows imaging with a high-frequency transducer over a short distance to generate high-resolution ultrasonographic images. EUS is now a widely accepted modality for diagnosing pancreatobiliary diseases. EUS-guided fine-needle aspiration (EUS-FNA) using a curved linear-array echoendoscope was initially described more than 20 years ago, and since then many researchers have expanded its indications to sample diverse lesions and have also used it for various therapeutic purposes. EUS-guided biliary drainage (EUS-BD) is one of the therapeutic procedures that has been developed using a curved linear-array echoendoscope. Technically, EUS-BD includes rendezvous techniques via transesophageal, transgastric, and transduodenal routes, EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS). Published data have demonstrated a high success rate, albeit with a comparatively high rate of nonfatal complications for EUS-CDS and EUS-HGS, and a comparatively low success rate with a low complication rate for the rendezvous technique. At present, these procedures represent an alternative to surgery or percutaneous transhepatic biliary drainage (PTBD) for patients with obstructive jaundice when endoscopic biliary drainage (EBD) has failed. However, these procedures should be performed in centers with extensive experience in linear EUS and therapeutic biliary ERCP. Large prospective studies are needed in the near future to establish standardized EUS-BD procedures as well as to perform controlled comparative trials between EUS-BD and PTBD, between rendezvous techniques and direct-access techniques (EUS-CDS and EUS-HGS), and between EBD and EUS-BD.