Technical tips of endoscopic ultrasound-guided choledochoduodenostomy

Abstract

Endoscopic ultrasound (EUS) is clinically useful not only as a diagnostic tool during EUS-guided fine needle aspiration, but also during interventional EUS. EUS-guided biliary drainage has been developed and performed by experienced endoscopists. EUS-guided choledocoduodenostomy (EUS-CDS) is relatively well established as an alternative biliary drainage method for biliary decompression in patients with biliary obstruction. The reported technical success rate of EUS-CDS ranges from 50% to 100%, and the clinical success rate ranges from 92% to 100%. Further, the over-all technical success rate was 93%, and clinical success rate was 98%. Based on the currently available literature, the overall adverse event rate for EUS-CDS is 16%. The data on the cumulative technical and clinical success rate for EUS-CDS is promising. However, EUS-CDS can still lead to several problems, so techniques or devices that are more feasible and safe need to be established. EUS-CDS has the potential to become a first-line biliary drainage procedure, although standardizing the technique in multicenter clinical trials and comparisons with endoscopic biliary drainage by randomized clinical trials are still needed.

Keywords: Endoscopic ultrasound; Endoscopic ultrasound-guided biliary drainage; Endoscopic ultrasound-guided choledochoduodenostomy; Percutaneous transhepatic biliary drainage.

Figure 1

Endoscopic ultrasound-guided choledocoduodenostomy combined with duodenal stent. A: Endoscopic ultrasound-guided choledocoduodenostomy (EUS-CDS) was performed from duodenal bulb after duodenal stenting; B: Endoscopic view of EUS-CDS combined with duodenal stent.

Figure 2

Double puncture of duodenal mucosa. A: Double mucosa of duodenum on endoscopic ultrasound view (arrow); B: Endoscopic view of double puncture of duodenal mucosa.

Figure 3

Novel endoscopic ultrasound-guided fine needle aspiration needle (Sono Tip Pro Control 19 G needle, Medi-Globe GmbH, Rosenheim, Germany). The cut surface of this fine needle aspiration needle is 5 mm, and this needle has sharpness.

Figure 4

Cyst-wire (Medi-Globe GmbH, Rosenheim, Germany). To avoid wire sharing, top formation of this guidewire is coil.

Figure 5

Cysto-Gastro-Set (Endoflex, GmbH, Voerde, Germany). This devise is always coaxial with the guidewire.

Figure 6

Bile leak due to plastic stent of endoscopic ultrasound-guided choledocoduodenostomy. A: Endoscopic view of day 1; B: Day 2; C: Day 3; D: Computed tomography showed bile leak (arrow).