Enteroscopy‑ERCP Cannot Replace the Role of Percutaneous Transhepatic Biliary Drains in Treating Biliary‑Enteric Anastomotic Strictures

Abstract

We read the important article by Hammad et al. [1] with great interests. The authors have done a great job of compar‐ ing the application result of enteroscopy‐ERCP and PTBD in treating biliary‐enteric anastomotic strictures. The authors draw the conclusion that E‐ERCP should be considered as an alternative to PTBD in AS treatment. This conclusion is disputed and not acceptable to our knowledge. As the authors said, initial decision making in select‐ ing the treatment was solely based on referring physician’s preference. Indications for choosing E‐ERCP or PTBD were based on upstream biliary ductal dilatation and elevated hepatic enzymes. Patients with severe bile duct enlarge‐ ment were more likely to receive PTBD treatment. Severe enlargement of the bile duct would lead to higher elevated hepatic enzyme levels. In this article, a more than 50% LFTs reduction was thought as a significant clinical improvement. As a result, the PTBD treatment group will need a rela‐ tive longer time to achieve that standard compared with the E‐ERCP group. In the E‐ERCP group, 14 of 34 patients received balloon dilation alone and the other patients received the combina‐ tion therapy of cautery, balloon dilation and passage diators with or without stent placement. While in PTBD group, bal‐ loon dilation and external/internal–external drainage were used. Yun et al. [2] have demonstrated that PTBD with stent placement can provide shorter PTBD indwelling time com‐ pared with only balloon dilatation. Regarding the 11 patients who failed to receive the E‐ERCP initially, 10 of them successfully received PTBD and one patient received repeated E‐ERCP. Thus, the total technical success rate of E‐ERCP was 77.8% (35/45). How‐ ever, in the group of PTBD, four of the six patients who failed to receive the PTBD initially got successful repeated PTBD and two of them got successful E‐ERCP. The total technical success rate for PTBD was 92.3% (24/26). Obvi‐ ously, the total technical success rate for PTBD group was higher than E‐ERCP group. The reasons why patients failed to receive the E‐ERCP or PTBD at the first time were different. The inability to reach the biliary‐enteric anastomosis and deeply cannulate the bile ducts were two major reasons for the E‐ERCP group. While in the PTBD group, the inability to advance wire beyond the stenosis was thought as the main reason. Four of the six patients succeed in their second trail which highly depends on the clinical experience of operators. Based on the discussion above, whether the E‐ERCP could be treated as an alternative to the PTBD still requires negotiations. The therapeutic strategy of biliary‐enteric anastomotic strictures should take individual stenosis con‐ dition into account.