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Review
. 2023 Dec 8;13(24):3623.
doi: 10.3390/diagnostics13243623.

Endoscopic Biliary Drainage in Surgically Altered Anatomy

Marco Spadaccini  1   2 , Carmelo Marco Giacchetto  1 , Matteo Fiacca  1 , Matteo Colombo  1 , Marta Andreozzi  1 , Silvia Carrara  1 , Roberta Maselli  1   2 , Fabio Saccà  1 , Alessandro De Marco  1   2 , Gianluca Franchellucci  1   2 , Kareem Khalaf  3 , Glenn Koleth  4 , Cesare Hassan  1   2 , Andrea Anderloni  5 , Alessandro Repici  1   2 , Alessandro Fugazza  1
Affiliations
Review

Endoscopic Biliary Drainage in Surgically Altered Anatomy

Marco Spadaccini et al. Diagnostics (Basel). .

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the preferred method for managing biliary obstructions. However, the prevalence of surgically modified anatomies often poses challenges, making the standard side-viewing duodenoscope unable to reach the papilla in most cases. The increasing instances of surgically altered anatomies (SAAs) result from higher rates of bariatric procedures and surgical interventions for pancreatic malignancies. Conventional ERCP with a side-viewing endoscope remains effective when there is continuity between the stomach and duodenum. Nonetheless, percutaneous transhepatic biliary drainage (PTBD) or surgery has historically been used as an alternative for biliary drainage in malignant or benign conditions. The evolving landscape has seen various endoscopic approaches tailored to anatomical variations. Innovative methodologies such as cap-assisted forward-viewing endoscopy and enteroscopy have enabled the performance of ERCP. Despite their utilization, procedural complexities, prolonged durations, and accessibility challenges have emerged. As a result, there is a growing interest in novel enteroscopy and endoscopic ultrasound (EUS) techniques to ensure the overall success of endoscopic biliary drainage. Notably, EUS has revolutionized this domain, particularly through several techniques detailed in the review. The rendezvous approach has been pivotal in this field. The antegrade approach, involving biliary tree puncturing, allows for the validation and treatment of strictures in an antegrade fashion. The EUS-transmural approach involves connecting a tract of the biliary system with the GI tract lumen. Moreover, the EUS-directed transgastric ERCP (EDGE) procedure, combining EUS and ERCP, presents a promising solution after gastric bypass. These advancements hold promise for expanding the horizons of comprehensive and successful biliary drainage interventions, laying the groundwork for further advancements in endoscopic procedures.

Keywords: ERCP; EUS; EUS-BD; altered anatomy; biliary drainage; surgery.

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Conflict of interest statement

Alessandro Fugazza is a consultant for Boston Scientific; Marco Spadaccini is a consultant for Boston Scientific; Matteo Colombo is a consultant for Boston Scientific; Alessandro Repici is a consultant for Boston Scientific, ERBE, Fujifilm; Silvia Carrara is a consultant for Olympus. There are no other conflicts of interested among the remaining authors.

Figures

Figure 1
Figure 1
Surgically altered anatomies. Type I: (A) Billroth I gastrectomy; (B) sleeve gastrectomy. Type II: (C) Roux-en-Y gastric bypass; (D): Billroth 2 gastrectomy; (E): Whipple procedure.
Figure 2
Figure 2
Underwater technique for reaching the papilla; radiological and endoscopic view.
Figure 3
Figure 3
EUS-AI Biliary stenting for the treatment of unresectable malignant biliary obstruction performed at the Humanitas Research Hospital.
Figure 4
Figure 4
EUS-HGS with a new dedicated partially covered self-expandable metal stent with anti-migratory systems. EUS-HGS: EUS hepaticogastrostomy.
See this image and copyright information in PMC

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