Endoscopic ultrasonography-guided biliary drainage: Who, when, which, and how?

Abstract

Both endoscopic ultrasonography (EUS)-guided choledochoduodenostomy (EUS-CDS) and EUS-guided hepaticogastrostomy (EUS-HGS) are relatively well established as alternatives to percutaneous transhepatic biliary drainage (PTBD). Both EUS-CDS and EUS-HGS have high technical and clinical success rates (more than 90%) in high-volume centers. Complications for both procedures remain high at 10%-30%. Procedures performed by endoscopists who have done fewer than 20 cases sometimes result in severe or fatal complications. When learning EUS-guided biliary drainage (EUS-BD), we recommend a mentor's supervision during at least the first 20 cases. For inoperable malignant lower biliary obstruction, a skillful endoscopist should perform EUS-BD before EUS-guided rendezvous technique (EUS-RV) and PTBD. We should be select EUS-BD for patients having altered anatomy from malignant tumors before balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography, EUS-RV, and PTBD. If both EUS-CDS and EUS-HGS are available, we should select EUS-CDS, according to published data. EUS-BD will potentially become a first-line biliary drainage procedure in the near future.

Keywords: Endoscopic ultrasonography; Endoscopic ultrasonography-guided biliary drainage; Endoscopic ultrasonography-guided choledochoduodenostomy; Endoscopic ultrasonography-guided rendezvous technique; Interventional endoscopic ultrasonography.

Figure 1

Endoscopic ultrasonography-guided biliary drainage algorithm for inoperable malignant lower biliary obstruction. Flow chart for management of inoperable malignant lower biliary obstruction. This algorithm is proposed for use by experts in endoscopic ultrasonography-guided biliary drainage. Our recommendations are large red arrows.

Figure 2

Stent patency in endoscopic ultrasonography-guided choledochoduodenostomy patients. Median stent patency in endoscopic ultrasonography-guided choledochoduodenostomy patients patients was 119 days for plastic stents and 419 d for metal stents. Logrank: HR = 0.3888, 95%CI: 0.19453-0.61081, P < 0.001.

Figure 3

Patency of endoscopic ultrasonography-guided choledochoduodenostomy after double stenting. After double stenting, median choledochoduodenostomy patency was 198 d. EUS-CDS: Endoscopic ultrasonography-guided choledochoduodenostomy.

Figure 4

Stent migration into abdominal cavity. There is wide space between the liver and stomach in some cases.

Figure 5

Focal cholangitis due to endoscopic ultrasonography-guided hepaticogastrostomy. Two days after endoscopic ultrasonography-guided hepaticogastrostomy, focal cholangitis occurred after blockage of the peripheral bile duct by the metal stent.

Figure 6

Liver abscess due to endoscopic ultrasonography-guided hepaticogastrostomy. Liver abscess occurred after blockage of the peripheral bile duct by the metal stent.

Figure 7

Bile duct stenosis caused by hyperplasia. Hyperplasia caused by placement of a metal stent that was too large for the peripheral bile duct.

Figure 8

Double penetration of the duodenum. Double penetration of the duodenum is a unique complication of endoscopic ultrasonography-guided choledochoduodenostomy that is performed using the oblique view.

Figure 9

Endoscopic ultrasonography-guided biliary drainage algorithm for management of inoperable malignant lower biliary obstruction suggested for the near future. Endoscopic ultrasonography-guided biliary drainage will be first-line biliary drainage method instead of endoscopic retrograde cholangiopancreatography, in our opinion. Percutaneous transhepatic biliary drainage will persist as the last-resort procedure. EUS-BD: Endoscopic ultrasonography-guided biliary drainage; EUS-CDS: Endoscopic ultrasonography-guided choledochoduodenostomy; EUS-HES: Endoscopic ultrasonography-guided hepaticogastrostomy; PTBD: Percutaneous transhepatic biliary drainage.