Endoscopic Ultrasound-guided Biliary Drainage

Hyeong Seok Nam; Dae Hwan Kang

doi:10.4166/kjg.2017.69.3.164

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Nam and Kang: Endoscopic Ultrasound-guided Biliary Drainage

Review Article

Korean J Gastroenterol 2017;69(3):164-171.

Published online: 4 October 2017

DOI: https://doi.org/10.4166/kjg.2017.69.3.164

Endoscopic Ultrasound-guided Biliary Drainage

Hyeong Seok Nam^1,², Dae Hwan Kang^1,²

¹Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea

²Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea

Correspondence to: Dae Hwan Kang, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea. Tel: +82-55-360-1538, Fax: +82-55-360-1536, E-mail: sulsulpul@naver.com

Received 17 February 2017 Revised 1 March 2017 Accepted 2 March 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The therapeutic role of endoscopic ultrasound (EUS) has continued to evolve in recent years. EUS-guided biliary drainage (EUS-BD) can be performed as an effective alternative to percutaneous drainage or surgical options when conventional Endoscopic retrograde cholangiopancreatography fails or is not possible. Depending on the access and exit routes of the stent, multiple approaches to EUS-BD have been proposed. Each patient should receive an individualized approach based on the patient's condition, anatomy, and endoscopist's experience, with an appropriate backup prepared. In high-volume centers, the cumulative success rate has been reported to be over 90%. However, the reported overall complication rate remains relatively high at 10–30%. Further studies are necessary to better understand the long-term results and standardize EUS-BD, including appropriate indications and optimal approach.

Keywords: Endoscopic ultrasonography, Drainage, Cholangiopancreatography, Endoscopic retrograde, Biliary tract

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Fig. 1.

Endoscopic ultrasound-guided rendezvous procedure. (A) Cholangiogram revealing a dilated bile duct after common bile duct puncture from the duodenal bulb. (B) A guidewire passed anterograde through the needle across the obstruction and into the duodenum. (C) Withdrawal and remove the endoscopic ultrasound. (D) Stent catheter placed into the bile duct using the duodenoscope. (E, F) Advancement of the stent delivery system across the obstruction and deployment of a metal stent across the obstruction.

Fig. 2.

Endoscopic ultrasound-guided choledochoduodenostomy. (A) Puncture of the common bile duct under endoscopic ultrasound. (B) Cholangiogram revealing a dilated bile duct after the needle puncture from the duodenal bulb. (C) Deployment of a metal stent via fistula tract between the bile duct and the duodenal bulb. (D) Endoscopic view of the deployed metal stent.

Fig. 3.

Endoscopic ultrasound-guided hepaticogastrostomy. (A) Color flow Doppler of the left liver before puncture. (B) Puncture of the left hepatic duct under endoscopic ultrasound. (C) Fluoroscopic view of puncture of the left hepatic duct by ultrasonography with contrast injection. (D) Deployment of a metal stent across the obstruction. (E) Endoscopic view of the deployed metal stent.

Fig. 4.

Endoscopic ultrasound-guided antegrade procedure. (A) Cholangiogram revealing a dilated intrahepatic bile duct after the needle puncture from the stomach. (B, C) A guidwire placed into the duodenum via the stenosis and dilation. (D) Antegradely inserted metal stent which is placed into the duodenum via papilla.

Table 1.

Generally Accepted Indications for Endoscopic Ultrasound-guided Biliary Drainage

Failed conventional ERCP

Ampullary distorsion or diverticulum

Tumor infiltration of the papilla

Ductal stricture; failed guidewire access, failed stent insertion

Difficult anatomy

Altered anatomy

Roux-en-Y gastrectomy, Billoth II gastrectomy, Biliopancreatic diversion, Bariatric bypass, etc.

Tumor preventing access into the biliary tree

Tumor infiltration of the papilla

Gastric outlet obstruction

Duodenal stenosis / in situ duodenal stent

Contraindication to percutaneous access (ascites, etc.)

ERCP, endoscopic retrograde cholangiopancreatography.

Table 2.

Techniques Approaches to Endoscopic Ultrasound-guided Biliary Drainage

Access

- Intrahepatic: transesophageal, transgastric or transjejunal(in altered anatomy)

- Extrahepatic: gastric antral or duodenal

Drainage

-Biliary stent placement

Transhepatic

- Transluminal: hepaticogastrostomy (EUS-HGS)

- Transpapillary: antegrade procedure (EUS-AG)

Transduodenal

- Transluminal: choledochoduodenostomy (EUS-CDS)

Biliary access for ERCP completion

- Rendezvous procedure (EUS-RV)

Adapted from Gastrointest Interv 2016;5:203–211.¹⁵

EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; EUS-AG, endoscopic ultrasound-guided antegrade procedure; EUS-CDS, endoscopic ultrasound-guided choledocoduodenostomy; ERCP, endoscopic retrograde cholangiopancreatography; EUS-RV, endoscopic ultrasound- guided rendezvous procedure.

Table 3.

Comparison of Approach Routes during Endoscopic Ultrasound-guided Rendezvous Technique

Scope position	IHBD	EHBD
Scope position	Straight	Push (long)	Pull (short)
Schema
Puncture site	Stomach	D1	D2
Scope stability	Stable	Stable	Unstable
Needle maneuverability	Easy	Difficult	Normal
Diameter of bile duct	Small	Large	Large
Needle direction	Ampulla	Hepatic hilar	Ampulla
Distance to papilla	Long	Short	Very short

Adapted from the article of Takuji Iwashita, M.D., Ph.D, Iwashta et al.¹⁶ (Clin J Gastroenterol 2014;7:94–102)

IHBD, intra hepatic bile duct; EHBD, extra hepatic bile duct; D1, duodenal bulbs; D2, 2nd portion of the duodenum.

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