EUS-guided biliary drainage for postsurgical anatomy

Abstract

ERCP is the mainstay of therapy for pancreatobiliary diseases in patients with native upper gastrointestinal (UGI) anatomy. However, when UGI anatomy is surgically altered, standard ERCP becomes technically challenging or not possible. In such instances, EUS-guided biliary drainage (EUS-BD) has been increasingly employed by advanced endoscopists as a safe and effective method of access to the biliary tree. In this study, we review the technical aspects and outcomes of EUS-BD in patients with surgical UGI anatomy.

Keywords: Advanced endoscopy; ERCP; EUS; Roux-en-Y gastric bypass; advanced endoscopy; bariatric surgery; biliary access; biliary stones; cholangiography; new technologies; surgically altered anatomy.

Figure 1

EUS-guided choledochoduodenostomy in a 53-year-old male for recurrent cholangitis status postorthotopic liver transplantation with Roux-en-Y hepaticojejunostomy and hepaticojejunostomy stricture. (a and b) Linear echoendoscope was advanced to D1 and the dilated bile duct was identified. (c) Under EUS guidance, a 19-gauge needle was advanced into the bile duct, and a cholangiogram was performed by injecting contrast. (d) A 0.025-inch guidewire was advanced through the needle into the intrahepatic ducts. A 10 mm × 40 mm fully covered self-expanding metal stent was advanced over the wire and deployed successfully creating the choledochoduodenostomy. (e) A 7 Fr × 5 cm double-pig tail was deployed through the fully covered self-expanding metal stent to avoid stent migration. (f) On a different session, the two stents were removed, and pediatric gastroscope was advanced through the created choledochoduodenostomy. Cholangiogram revealed diffuse intrahepatic strictures with beaded appearance

Figure 2

EUS-hepatogastrostomy for malignant biliary obstruction in a 75-year-old male status postpartial gastrectomy and Roux-en-Y reconstruction for gastric cancer. (a) Significant dilatation of the common bile duct can be appreciated in the magnetic resonance imaging. (b) A linear echoendoscope was advanced to the stomach. Following the identification of the left intrahepatic duct, a 19-gauge needle was advanced transgastrically into the left intrahepatic duct. (c and d) Contrast was injected and anterograde cholangiography was performed, confirming correct positioning within the biliary tree. Dilatation of the intrahepatic and extrahepatic bile ducts can be appreciated. (e and f) A guidewire was passed into the left hepatic duct across the hilum into the common hepatic duct. (g) A 7 Fr × 10 cm plastic stent with internal and external flaps was placed over the wire into the left intrahepatic duct. (h) Endoscopic view of the deployed plastic stent

Figure 3

EUS-directed transenteric ERCP for choledocholithiasis in a 50-year-old male with a history of Roux-en-Y hepaticojejunostomy due to bile duct injury postcholecystectomy. (a and b) The endoscope was advanced to the jejunum, and a mixture of contrast and saline was injected into the afferent limb, confirming correct position. (c) The endoscope was withdrawn, and a linear EUS was advanced to the duodenum and a location suitable for the duodenojejunal anastomosis was established under fluoroscopy. (d) The small bowel was punctured with a 19-G FNA needle. The small bowel adjacent to the hepaticojejunostomy anastomosis was dilated using 330 cc of saline mixed with contrast. Under EUS guidance, a cautery-assisted lumen-apposing metal stent, 15 mm × 10 mm, was then deployed creating the duodenojejunostomy. (e) Endoscopic view of the proximal flange of lumen-apposing metal stent post-deployment. (f) Under fluoroscopic guidance, using a therapeutic gastroscope, a guidewire was advanced across the lumen-apposing metal stent and hepaticojejunostomy was successfully cannulated

Figure 4

Our approach to managing complex pancreatobiliary pathology. RYGB: Roux-en-Y Gastric Bypass, EDGE: EUS-directed transgastric ERCP, EUS-RV: EUS-rendezvous, EUS-HGS: EUS-guided hepatogastrostomy, EUS-HJS: EUS-guided hepaticojejunostomy, EUS-BD: EUS-guided biliary drainage, EDEE: EUS-directed transenteric ERCP, PTBD: Percutaneous transhepatic biliary drainage