How to perform EUS-guided biliary drainage

Abstract

EUS-guided biliary drainage (EUS-BD) has recently gained widespread acceptance as a minimally invasive alternative method for biliary drainage. Even in experienced endoscopy centers, ERCP may fail due to inaccessibility of the papillary region, altered anatomy (particularly postsurgical alterations), papillary obstruction, or neoplastic gastric outlet obstruction. Biliary cannulation fails at first attempt in 5%-10% of cases even in the absence of these factors. In such cases, alternative options for biliary drainage must be provided since biliary obstruction is responsible for poor quality of life and even reduced survival, particularly due to septic cholangitis. The standard of care in many centers remains percutaneous transhepatic biliary drainage (PTBD). However, despite the high technical success rate with experienced operators, the percutaneous approach is more invasive and associated with poor quality of life. PTBD may result in long-term external catheters for biliary drainage and carry the risk of serious adverse events (SAEs) in up to 10% of patients, including bile leaks, hemorrhage, and sepsis. PTBD following a failed ERCP also requires scheduling a second procedure, resulting in prolonged hospital stay and additional costs. EUS-BD may overcome many of these limitations and offer some distinct advantages in accessing the biliary tree. Current data suggest that EUS-BD is safe and effective when performed by experts, although SAEs have been also reported. Despite the high number of clinical reports and case series, high-quality comparative studies are still lacking. The purpose of this article is to report on the current status of this procedure and to discuss the tools and techniques for EUS-BD in different clinical scenarios.

Keywords: ERCP; EUS; EUS-guided biliary drainage; EUS-guided gallbladder drainage; acute cholecystitis; obstructive jaundice.

Figure 1

Normal anatomy – Rendezvous

Figure 2

Normal anatomy – Gallbladder drainage

Figure 3

Normal anatomy – CDS retrograde. CDS: Choledochoduodenostomy

Figure 4

Normal anatomy – CDS antegrade. CDS: Choledochoduodenostomy

Figure 5

Normal anatomy – CDS retrograde. CDS: Choledochoduodenostomy

Figure 6

Normal anatomy – HGS antegrade. HGS: Hepaticogastrostomy

Figure 7

Normal anatomy – HGS retrograde. HGS: Hepaticogastrostomy

Figure 8

Normal anatomy – Bridging and HGS retrograde. HGS: Hepaticogastrostomy

Figure 9

Altered anatomy – HGS retrograde. HGS: Hepaticogastrostomy

Figure 10

Altered anatomy – HGS antegrade. HGS: Hepaticogastrostomy

Figure 11

EUS-CDS. Anatomy dilated CBD (a), puncture (b), guidewire placement (c), and stent placement (d). CBD: common bile duct; CHA common hepatic artery; PV portal vein; SEMS self expanding metal stent; CDS: Choledochoduodenostomy

Figure 12

HGS. Dilated intrahepatic duct segment 2 (a). Needle (b). Dilated intrahepatic duct segment 2, fluoroscopy (c). Guidewire (d). Electrocautery ring knife (e). Dilation fistula (f). Placement SEMS retrograde (g). HGS: Hepaticogastrostomy