EUS-Guided Biliary Drainage

Abstract

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.

Keywords: Endoscopic ultrasonography; Endoscopic ultrasonography-guided biliary drainage; Endoscopic ultrasonography-guided choledochoduodenostomy; Endoscopic ultrasonography-guided hepaticogastrostomy; Rendezvous technique.

Fig. 1

Endoscopic ultrasonography-guided biliary drainage with a rendezvous technique. (A) After the echoendoscope was positioned in the esophagus and the slightly dilated intrahepatic bile ducts were visualized by endosonography, the bile ducts were punctured with a 19- or 22-gauge needle. (B) After successful intraductal bile duct puncture, a guide wire was advanced distally through the stricture and the papilla by fluoroscopy. (C) The guide wire was grasped with a snare and pulled back out the working channel of the duodenoscope for subsequent over-the-wire cannulation. (D) Endoscopic retrograde cholangiography with stent placement was achieved over the guide wire.

Fig. 2

Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS). (A) Convex echoendoscope, located in the apex of the duodenal bulb, clearly displayed the extrahepatic bile duct and cystic duct. (B) The echoendoscope was observed in the long/pushing scope position. Cholangiogram obtained by EUS-guided puncture with the tip of the convex transducer directed to the hepatic hilum. (C) Choledochoduodenostomy was accomplished using a plastic stent in the apex of the duodenal bulb. (D) The plastic stent was visible in the first portion of the duodenum. (E) The covered metal stent was also available for EUS-CDS.

Fig. 3

Guide wire-assisted stent exchange. (A) A 0.035-inch guide wire was inserted into the bile duct through an occluded stent using an ERCP catheter. (B) The occluded stent was removed using a snare with the guidewire in place, through the biopsy channel of the duodenoscope.

Fig. 4

Endoscopic ultrasonography-guided hepatogastrostomy. (A) A dilated peripheral branch of the left intra-hepatic system that was accessed transgastrically using a 22-gauge needle. (B) A 7 Fr biliary plastic stent was inserted though the hepaticogastrosotomy site into intrahepatic bile ducts.