Endoscopic Management for Difficult Biliary Cases in the era of Laparoscopic Surgery

Abstract Background: Biliary disorders are still the most challenging cases in the field of gastroenterology, as comprehensive clinical evaluation and treatment considerations are still necessary. In the era of laparoscopic procedure, there are a lot of innovations on non-surgical management approaches, such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). Since there is no clear consensus yet in managing complicated biliary disorders, this study is aimed to see the impact of endoscopic management for difficult biliary cases. Methods: A cohort-retrospective endoscopy database study was conducted at a tertiary-referral private hospital in Jakarta, Indonesia, between January and December 2020. Difficult biliary cases defined as biliary case which required at least one of the following conditions: multi-management approach, biliary obstruction with cholangitis or biliary sepsis, difficult CBD stone, recurrent CBD stone, or advanced progressive malignant biliary obstruction. Results: Sixty-one subjects in this retrospective database study were suitable as difficult biliary cases. The proportions of malignant and non-malignant etiologies were similar (44.3% versus 55.7%, respectively). In this study, 68.8% of all subjects underwent standard therapeutic ERCP procedure, while 16.4% of the subjects underwent combination of therapeutic ERCP and EUS in one session based on the complexity of the case; and 8.2% of the subjects underwent therapeutic ERCP with additional single operator cholangioscopy procedure. One subject underwent rendezvous ERCP procedure through percutaneous approach. Around 4.9% of the subjects underwent EUS-biliary drainage procedure. The technical success rate of all procedures was 100%. Re-intervention ERCP was performed in 6 subjects (9.8%). No significant association was observed between all mortality outcomes and baseline characteristics of the patients. There were also no significant associations between re-intervention procedures, as well as post-procedural pain or acute pancreatitis, with mortality outcomes. Conclusion: Difficult biliary cases require a good clinical approach algorithm to decide which procedure comes first based on comprehensive evaluation consists of patient’s factor, expertise, cost, and the risk of complications.