Efficacy and safety of EUS biliary drainage in malignant distal and hilar biliary obstruction: A comprehensive review of literature and algorithm

Abstract

Malignant biliary obstruction (MBO) encompasses a variety of malignancies arising from the pancreaticobiliary system. This can be divided into malignant hilar biliary obstruction (MHBO) or malignant distal biliary obstruction (MDBO) biliary obstruction to which clinical outcomes and technical considerations of various biliary drainage methods may differ. EUS biliary drainage (EUS-BD) has been increasingly influential in the management of MBO together with other familiar biliary drainage methods such as ERCP and percutaneous transhepatic biliary drainage (PTBD). Conventionally, ERCP has always been the primary choice of endoscopic biliary drainage in both MHBO and MDBO and that PTBD or EUS-BD is used as a salvage method when ERCP fails for which current guidelines recommends PTBD, especially for MHBO. This review was able to show that with today's evidence, EUS-BD is equally efficacious and possesses a better safety profile in the management of MBO and should be on the forefront of endoscopic biliary drainage. Therefore, EUS-BD could be used either as a primary or preferred salvage biliary drainage method in these cases.

Keywords: ERCP; EUS; EUS-guided biliary drainage; Klatskin's tumor; endosonography; hilar cholangiocarcinoma; malignant distal biliary obstruction; malignant hilar biliary obstruction; perihilar cholangiocarcinoma.

Figure 1

(a) EUS-hepaticogastrostomy to left intrahepatic duct combined with ERCP to the right intrahepatic duct. (b) EUS-hepaticoduodenostomy to right intrahepatic duct combined with ERCP to the right intrahepatic duct.

Figure 2

Proposed algorithm for EUS-BD in unresectable malignant biliary obstruction. AS: Anterograde stenting; CDS: Choledochoduodenostomy; EUS-BD: EUS-guided biliary drainage; CERES: Combined ERCP and EUS-BD; HGS: Hepaticogastrostomy; RV: Rendezvous procedure