Endoscopic Ultrasound-Guided Pancreatobiliary Endoscopy in Surgically Altered Anatomy

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of therapy for pancreatobiliary diseases. While ERCP is safe and highly effective in the general population, the procedure remains challenging or impossible in patients with surgically altered anatomy (SAA). Endoscopic ultrasound (EUS) allows transmural access to the bile or pancreatic duct (PD) prior to ductal drainage using ERCP-based techniques. Also known as endosonography-guided cholangiopancreatography (ESCP), the procedure provides multiple advantages over overtube-assisted enteroscopy ERCP or percutaneous or surgical approaches. However, the procedure should only be performed by endoscopists experienced in both EUS and ERCP and with the proper tools. In this review, various EUS-guided diagnostic and therapeutic drainage techniques in patients with SAA are examined. Detailed step-by-step procedural descriptions, technical tips, feasibility, and safety data are also discussed.

Keywords: Antegrade drainage; Endoscopic ultrasound; Rendezvous; Surgically altered anatomy; Transmural drainage.

Fig. 1.

Common surgically altered anatomy (SAA). (A) Billroth II anatomy (Adapted from Cameron JL. [11]). (B) Roux-en-Y gastric bypass (RYGB) anatomy (Adapted from Cameron JL. [11]). (C) Pancreaticoduodenectomy (Whipple) anatomy (Adapted from Johnes DB et al. [12]). GJ, gastrojejunal; JJ, jejunojejunal; PJ, pancreaticojejunostomy; CJ, choledochojejunal.

Fig. 2.

Forward-viewing (FV) echoendoscope (photo provided by Olympus, Center Valley, PA, USA).

Fig. 3.

19 Gauge endoscopic ultrasound (EUS) access needle (Cook Medical, Bloomington, IN, USA). (A) Beveled stylet. (B) Blunt needle tip.

Fig. 4.

EUS-guided biliary drainage (EUS-BD) algorithm in surgically altered anatomy (SAA). ERC, endoscopic retrograde cholangiography; EUS, endoscopic ultrasound; IH, intrahepatic.

Fig. 5.

Endoscopic ultrasound (EUS)-guided transmural drainage: hepaticogastrotomy. (A) EUS-guided intrahepatic (IH) access with 19 G needle. (B) Cholangiogram via EUS showing dilated left IH ducts. (C) Balloon dilation of hepaticogastrostomy (HG). (D) Fluoroscopic view of fully covered self-expandable metallic stents (SEMS) across HG. (E) Endoscopic view of fully covered SEMS across HG.

Fig. 6.

Endoscopic ultrasound (EUS)-guided pancreatic drainage algorithm in surgically altered anatomy (SAA). ERP, endoscopic retrograde pancreatography; PANK, pancreatic antegrade needle-knife.

Fig. 7.

Endoscopic ultrasound (EUS)-guided pancreatic rendezvous in post-Whipple patient with anastomotic stricture. (A) EUS of dilated main pancreatic duct (MPD). (B) EUS-guided access to dilated main PD with 19 G needle. (C) Long 0.035-inch guidewire advanced through stenosed pancreaticojejunostomy (PJ) and coiled in jejunum. (D) Echoendoscope removed, leaving guidewire in place. Colonoscope advanced alongside guidewire and distal end captured with forceps to complete rendezvous. Left: fluoroscopic and right: endoscopic view. (E) Pancreatic stent placed across anastomosis via traditional endoscopic retrograde cholangiopancreatography (ERCP) using colonoscope. Courtesy of Dr. Christopher Thompson, Brigham and Women’s Hospital.

Fig. 8.

Endoscopic ultrasound (EUS)-guided antegrade transmural pancreatic drainage in post-Whipple patient with anastomotic stricture. (A) EUS-guided access of dilated pancreatic dust (PD) using 19 G needle. (B) EUS-guided pancreatogram demonstrating anastomotic stricture. (C) Long 0.035 in guidewire advanced through anastomotic stricture and coiled in jejunum. (D) Balloon dilation of stricture and pancreatogastrostomy (not shown). (E) Pigtail stent placed across anastomosis and pancreatogastrostomy seen endoscopically in the stomach. Courtesy of Dr. Christopher Thompson, Brigham and Women’s Hospital.

Fig. 9.

External endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP). (A) EUS-guided access of the remnant stomach using 22 G needle. (B) Contrast injection into the remnant stomach. (C) Percutaneous access into the remnant stomach using four T-tags, introducer needle, and guidewire. (D) Fully covered esophageal stent advanced over wire and balloon dilated to 18 mm. (E) Duodenoscope inserted through the stent to perform ERCP. (F) Stent exchanged for a gastrostomy tube. Courtesy of Dr. Christopher Thompson, Brigham and Women’s Hospital.