Inside Tract
July 15, 2013

Advances in endoscopy have yielded life-changing results for many people. But it’s hard to imagine anyone benefiting more than patients with malignant biliary obstruction.

For years, options were limited for patients with disorders of the pancreatic or biliary ducts. Surgery and implanted external drains are costly, impractical and often diminish quality of life.

Endoscopic retrograde cholangiography (ERCP) helps physicians diagnose problems directly and determine the best treatments. More recently, ERCP is itself an agent of therapy, in breaking strictures or implanting stents, for example. But according toMouen Khashab, director of therapeutic endoscopy at The Johns Hopkins Hospital, ERCP sometimes needs help. 

“In about 5 percent of cases, ERCP fails due to reasons like anatomy and a simple inability to move the scope or instruments through small spaces” he says. “Sometimes an obstructing cancer makes ERCP difficult or impossible.”

In the past, when ERCP failed but patients still needed biliary drainage, their physicians relied primarily on surgical procedures like percutaneous transhepatic cholangiography, or PTC. “That’s basically putting a stent from the bile duct to the skin,” Khashab says. “The problem with PTC, though, is that it’s invasive and patients have to deal with an external stent.”

But thanks to advances in scope design and the need for a less-invasive procedure, options are improving.

Khashab now favors using ultrasound to guide the scope through difficult spots. “It allows us to see through the gut wall and into the biliary tree and then, under its guidance, lets us place a drain between the GI tract and the biliary tree,” he says. Most important, he adds, it means an internal stent, not an external one.

“In the early 1980s, endoscopic ultrasound was mostly diagnostic,” says Khashab. “But in recent years, we’ve learned more about it—how to use the scopes in new ways. The scopes have gotten better and the therapeutic channels have gotten larger, so we can insert instruments through them. People understand endoscopy more, and we want to perform less-invasive procedures.

Khashab points to a recent case as a good example. “A patient had a very large tumor at the head of the pancreas and the anatomy wouldn’t allow me to do the ERCP,” he says. “So I brought him back the next morning, did the ultrasound endoscopy and was finished in 22 minutes,” he says. “The patient was really happy to have avoided the external drain.”