Endoscopic ultrasound-guided biliary drainage-current status and future perspectives

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction. ERCP could fail in cases of duodenal obstruction, duodenal diverticulum, ampullary neoplastic infiltration or surgically altered anatomy. In these cases percutaneous biliary drainage (PTBD) is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices. A large amount of data is already collected that proves its efficacy, safety and ability to replace PTBD in cases of ERCP failure. It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future. Several EUS-BD techniques are developed EUS-guided transmural stenting, antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy. EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure. The lack of training, absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure, which is related to life-threatening adverse events. Developing training models, dedicated devices and guidelines hopefully will make EUS-BD easier, safer and well accepted in the future. This paper focuses on the technical aspects of the different EUS-BD procedures, available literature data, advantages, negative aspects and the future perspectives of these modalities.

Keywords: Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound-guided antegrade stenting; Endoscopic ultrasound-guided biliary drainage; Endoscopic ultrasound-guided choledochoduodenostomy; Endoscopic ultrasound-guided hepaticogastrostomy; Endoscopic ultrasound-guided rendezvous technique; Malignant bile duct obstruction.

Figure 1

Left hepatic duct puncture and contrast injection. A: Cholangiogram; B: endoscopic ultrasound image.

Figure 2

Hydrophilic guidewire insertion. A: In left hepatic duct; B: To the distal common bile duct.

Figure 3

Tract dilatation. A: Biliary dilation catheter; B: 4 mm balloon dilatator.

Figure 4

Stent placement-self-expandable metal stent. A: Cholangiogram; B: Endoscopic image.

Figure 5

Endoscopic ultrasound-guided antegrade stenting. A: Left hepatic duct puncture with 19G needle; B: Guide-wire insertion; C: Tract dilatation and advancing the biliary catheter tip transpapillary in the duodenum; D: Self-expandable metal stent placement.

Figure 6

Endoscopic ultrasound-guided choledochoduodenostomy. A: Puncture of the common bile duct with 19G needle and contrast injection; B: Hydrophilic guidewire inserted through the needle into bile ducts; C: Fluoroscopic image of self-expandable metal stent (SEMS); D: Endoscopic image of SEMS.

Figure 7

Endoscopic ultrasound-guided rendezvous technique. A: Puncture the left hepatic duct with 19G needle; B: Guide-wire insertion in bile ducts; C: Guide-wire insertion transpapillary in the duodenum; D: Grasping the guide-wire with a rath tooth forceps; E: Endoscopic image of two self-expandable metal stent (SEMS); F: Fluoroscopic image of two SEMS.

Figure 8

Current place of endoscopic ultrasound-guided biliary drainage in endoscopic biliary drainage therapy. EUS-BD: Endoscopic ultrasound-guided biliary drainage; EUS-RV: EUS-guided rendezvous technique; EUS-AS: EUS-guided antegrade stenting; EUS-CDS: EUS-guided choledochoduodenostomy/choledochoantrostomy; EUS-HGS: EUS-guided hepaticogastrostomy.