Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction: A Comprehensive Review on Technical Tips and Clinical Outcomes

Abstract

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has dramatically spread and improved in the last two decades and is changing the paradigm of drainage in case of malignant biliary obstruction (MBO). EUS-BD can be achieved from different routes, including the common bile duct (choledochoduodenostomy), intrahepatic bile ducts (hepaticogastrostomy), and gallbladder as a rescue (cholecystogastrostomy/cholecystoduodenostomy). EUS-guided hepaticogastrostomy (EUS-HGS) is a valuable option for biliary drainage in MBO when ERCP fails or is not feasible. EUS-HGS has demonstrated high efficacy with a good rate of technical and clinical success. The safety profile is also overall favorable, although severe adverse events may occur in a significant proportion of patients. From a technical perspective, EUS-HGS is considered one of the most demanding procedures in biliopancreatic endoscopy, requiring multiple steps and high technical skills and experience. In this comprehensive review, technical tips and clinical outcomes of EUS-HGS are reviewed according to the latest evidence in the literature.

Keywords: biliary drainage; efficacy; endoscopic ultrasound; hepaticogastrostomy; malignant biliary obstruction; safety.

Figure 1

Example images of EUS-guided puncture of intrahepatic bile ducts at the lateral posterior branch (B2, on the left) or lateral anterior branch (B3, on the right). The difference in the scope tip angulation and position inside the stomach, as well as in the angulation between the needle axis and the bile cut, are clearly visible (yellow lines). These are original figures from the Gastroenterology and Digestive Endoscopy Unit, IRCCS San Matteo Hospital—Pavia, Italy.

Figure 2

Example images of guidewire manipulation inside the biliary tree during EUS-HGS. On the left, the guidewire has been advanced over the hilar stenosis, into the common bile duct. On the right, the progression of the guidewire over the papilla, into the duodenal lumen has been obtained. The latter is the best condition for subsequent maneuvers (i.e., dilation and stent positioning) in terms of stability of the wire and pushing force of the devices over the wire. These are original figures from the Gastroenterology and Digestive Endoscopy Unit, IRCCS San Matteo Hospital—Pavia, Italy.

Figure 3

Example images of fistulous tract dilation using a 6-french cystotome (on the left, yellow arrow) or a 4 mm balloon on the right (yellow arrow). The difference in the degree of dilation achievable is clearly visible. These are original figures from the Gastroenterology and Digestive Endoscopy Unit, IRCCS San Matteo Hospital—Pavia, Italy.

Figure 4

Example images deployed stent during EUS-HGS. On the left, a Giobor stent has been deployed (yellow arrow); the different shape of proximal (intrahepatic, dotted yellow lines) and distal (intragastric, yellow continuous lines) portion is clearly visible, as well as the passage between the uncovered portion, which is totally inside the bile duct, and the covered portion, which covers the fistulous tract and goes inside the stomach, are clearly visible. At endoscopic view, the proximal end of the stent released into the stomach is shown, with the flowing bile clearly visible. These are original figures from the Gastroenterology and Digestive Endoscopy Unit, IRCCS San Matteo Hospital—Pavia, Italy.