Primary endoscopic ultrasound-guided hepaticogastrostomy for biliary drainage prior to pancreatoduodenectomy: a retrospective study in Japan

Background/Aims: Malignant lesions of the pancreatic head can cause obstructive jaundice requiring biliary drainage. However, the effect of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and metal stents on surgical resection remains controversial. This study aimed to investigate the efficacy of primary endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) performed prior to pancreatoduodenectomy, excluding patients with biliary duct cancer. Methods: We retrospectively analyzed consecutive patients who underwent pancreatoduodenectomy at our institution between January 2019 and December 2022. The patients were divided into three groups: without biliary drainage (n=130), endoscopic biliary stenting (EBS) (n=57), and primary EUS-HGS (n=20). Results: The positivity rate of the intraoperative bile juice culture was significantly higher in the EBS group (p<0.001). No significant difference was observed among the groups in terms of postoperative adverse events (Clavien-Dindo grade 3 or higher, p=0.784) or the positive rate of peritoneal lavage cytology (p=0.984). Seven patients in the EBS group (12.3%) experienced early adverse events related to biliary drainage (post-ERCP pancreatitis, n=3; acute cholecystitis, n=3; bile duct perforation, n=1), whereas none in the EUS-HGS group experienced adverse events. Conclusions: Primary EUS-HGS is technically feasible as a preoperative procedure and has no short-term postoperative disadvantages.