To date, percutaneous transhepatic biliary drainage (PTBD) has been considered as the usual biliary access after failed endoscopic retrograde cholangiopancreatography (ERCP). Since endoscopic ultrasonography (EUS)-guided bile duct puncture was first described in 1996, sporadic case reports of EUS-guided biliary drainage (EUS-BD) have suggested it as an alternative to PTBD after failed ERCP. The potential benefits of EUS-BD include internal drainage, thus avoiding long-term external drainage in cases where external PTBD drainage catheters cannot be internalized. EUS-guided hepaticogastrostomy (EUS-HG) is one form of EUS-BD. This article describes the indications, techniques, and outcomes of published data on EUS-HG.
Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is the standard procedure for biliary drainage in patients with benign or malignant biliary obstruction, with a success rate of approximately 90% to 97% and a risk of complications less than 10%. Alternative biliary accesses are percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. PTBD is successful in 87% to 100% of cases, with a postprocedure adverse event rate of 9% to 33% and a mortality rate of 2% to 15%. Surgical bypass may also be considered an alternative, but this procedure can have relatively high postprocedure adverse event and mortality rates. To date, PTBD has been considered the most appropriate salvage of biliary access after failed ERCP. Since endoscopic ultrasonography (EUS)-guided bile duct puncture was first described in 1996, sporadic case reports of EUS-guided biliary drainage (EUS-BD) have suggested it as an alternative to PTBD after failed ERCP. The potential benefits of EUS-BD include that it is a 1-stage procedure, as with ERCP, and internal drainage, avoiding long-term external drainage in cases where external PTBD drainage catheters cannot be internalized; this can significantly improve the quality of life of terminally ill patients and possibly result in lower morbidity than PTBD or surgery.
EUS-guided hepaticogastrostomy (EUS-HG) is one form of EUS-BD. This method of access allows biliary drainage from the intrahepatic bile duct to the stomach. Previously, percutaneous hepaticogastrostomy was attempted, and achieved a high technical success rate but with 2 mortalities. This 2-stage approach, using fluoroscopic, laparoscopic, and endoscopic assistance, places a temporary fenestrated gastrostomy tube through the liver with the bumper in the stomach for 2 weeks, followed by a replacement metal biliary stent between the left biliary system and the stomach. Because of the complexity of the procedure and mortalities, this approach has not been widely used. Since EUS-HG with transluminal stenting was first reported by Burmester and colleagues in 2003, a few case series regarding this technique have been reported. Compared with percutaneous hepaticogastrostomy, EUS-HG can be performed as a 1-stage procedure in the same endoscopic session after failed ERCP.
This article describes the indications, techniques, and outcomes of published data on EUS-HG.
Indications for EUS-HG
Indications for EUS-HG include patients with proximal bile duct obstruction, surgically altered anatomy such as Roux-en-Y anastomosis, and duodenal bulb invasion after failed ERCP. In patients with an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary insertion of a metal stent, EUS-HG may be also considered as an alternative to PTBD after failed ERCP.
Compared with other EUS-BD techniques such as EUS-choledochoduodenostomy or rendezvous, EUS-HG with transluminal stenting (EUS-HGS) may be most appropriate in patients with surgically altered anatomy after failed ERCP, because of the difficult and often prolonged effort in passing the guide wire into the duodenum or small bowel with the EUS-guided rendezvous technique. Furthermore, EUS-HGS can eliminate the need for deep enteroscopy (in patients with surgically altered anatomy) to grasp the antegrade-placed guide wire placed via the EUS-HG rendezvous technique. The intent of EUS-HGS is to provide a permanent biliary diversion, whereas EUS-HG with the rendezvous technique is intended to facilitate access to the bile duct. Thus, EUS-HGS is most appropriate for palliative biliary drainage. In right-sided intrahepatic biliary obstruction or complex hilar biliary strictures such as Klatskin tumor Bismuth type III or IV, EUS-HGS may not be effective for such circumstances because EUS-HGS offers only left-sided biliary decompression ( Box 1 ).
- 1.
Proximal bile duct obstruction a after failed ERCP
- 2.
Surgically altered anatomy such as Roux-en-Y anastomosis after failed ERCP
- 3.
Duodenal bulb invasion after failed ERCP
- 4.
In patients with occluded biliary metal stent after a hilar bilateral metal stent b placement or after a combined duodenal and biliary metal stent placement, as an alternative to PTBD after failed ERCP
Notes:
1, 3, and 4: palliative biliary drainage for malignant biliary obstruction.
2: Benign or malignant biliary obstruction. Consider EUS-HGS or EUS-HG with rendezvous technique.
a Common hepatic duct or mid–common bile duct obstruction. Klatskin tumor Bismuth type ≥III may not be feasible.
b Left-sided hilar stricture (especially dilated bile duct segment 3 due to segmental tumor progression).
Technique of EUS-HG
After administration of prophylactic antibiotics, EUS-HG is performed using a linear-array echoendoscope, and the tip of the echoendoscope is placed at the cardia or lesser curvature of the stomach. EUS-HG is formed by puncturing dilated left intrahepatic biliary system with a 19-gauge needle. After removal of the stylet, bile is aspirated, and radiopaque contrast is injected to visualize the biliary system under fluoroscopy. A 0.035-in or 0.021-in guide wire is then passed via the needle into the left intrahepatic system. Every attempt should be made to pass the wire into the duodenum across the biliary stricture so that rendezvous ERCP drainage can be undertaken with transpapillary biliary stent placement. If this is not possible, the wire can be coiled in the liver hilum for transluminal stent placement. Transluminal stenting is performed in most cases because the passage of a transhepatically placed guide wire into the duodenum across the biliary stricture is technically challenging. For dilation of the transmural tract, a graded dilation can be used as in EUS-guided pseudocyst drainage ( Fig. 1 ). In brief, an ERCP cannula ultra-tapered to 4F is inserted over the guide wire. Then 6F and 7F biliary dilator catheters are inserted over the guide wire and removed, in that order, to dilate the tract. If there is resistance to the advancement of the 6F dilator catheter, a triple-lumen needle-knife with a 7F shaft diameter or a cystotome is gently inserted over the guide wire to dilate the tract using a brief burst of pure cutting current. A plastic stent or an expandable metal stent is then transgastrically deployed into the left intrahepatic system ( Figs. 2 and 3 ).
Indications for EUS-HG
Indications for EUS-HG include patients with proximal bile duct obstruction, surgically altered anatomy such as Roux-en-Y anastomosis, and duodenal bulb invasion after failed ERCP. In patients with an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary insertion of a metal stent, EUS-HG may be also considered as an alternative to PTBD after failed ERCP.
Compared with other EUS-BD techniques such as EUS-choledochoduodenostomy or rendezvous, EUS-HG with transluminal stenting (EUS-HGS) may be most appropriate in patients with surgically altered anatomy after failed ERCP, because of the difficult and often prolonged effort in passing the guide wire into the duodenum or small bowel with the EUS-guided rendezvous technique. Furthermore, EUS-HGS can eliminate the need for deep enteroscopy (in patients with surgically altered anatomy) to grasp the antegrade-placed guide wire placed via the EUS-HG rendezvous technique. The intent of EUS-HGS is to provide a permanent biliary diversion, whereas EUS-HG with the rendezvous technique is intended to facilitate access to the bile duct. Thus, EUS-HGS is most appropriate for palliative biliary drainage. In right-sided intrahepatic biliary obstruction or complex hilar biliary strictures such as Klatskin tumor Bismuth type III or IV, EUS-HGS may not be effective for such circumstances because EUS-HGS offers only left-sided biliary decompression ( Box 1 ).
- 1.
Proximal bile duct obstruction a after failed ERCP
- 2.
Surgically altered anatomy such as Roux-en-Y anastomosis after failed ERCP
- 3.
Duodenal bulb invasion after failed ERCP
- 4.
In patients with occluded biliary metal stent after a hilar bilateral metal stent b placement or after a combined duodenal and biliary metal stent placement, as an alternative to PTBD after failed ERCP
Notes:
1, 3, and 4: palliative biliary drainage for malignant biliary obstruction.
2: Benign or malignant biliary obstruction. Consider EUS-HGS or EUS-HG with rendezvous technique.
a Common hepatic duct or mid–common bile duct obstruction. Klatskin tumor Bismuth type ≥III may not be feasible.
b Left-sided hilar stricture (especially dilated bile duct segment 3 due to segmental tumor progression).
Technique of EUS-HG
After administration of prophylactic antibiotics, EUS-HG is performed using a linear-array echoendoscope, and the tip of the echoendoscope is placed at the cardia or lesser curvature of the stomach. EUS-HG is formed by puncturing dilated left intrahepatic biliary system with a 19-gauge needle. After removal of the stylet, bile is aspirated, and radiopaque contrast is injected to visualize the biliary system under fluoroscopy. A 0.035-in or 0.021-in guide wire is then passed via the needle into the left intrahepatic system. Every attempt should be made to pass the wire into the duodenum across the biliary stricture so that rendezvous ERCP drainage can be undertaken with transpapillary biliary stent placement. If this is not possible, the wire can be coiled in the liver hilum for transluminal stent placement. Transluminal stenting is performed in most cases because the passage of a transhepatically placed guide wire into the duodenum across the biliary stricture is technically challenging. For dilation of the transmural tract, a graded dilation can be used as in EUS-guided pseudocyst drainage ( Fig. 1 ). In brief, an ERCP cannula ultra-tapered to 4F is inserted over the guide wire. Then 6F and 7F biliary dilator catheters are inserted over the guide wire and removed, in that order, to dilate the tract. If there is resistance to the advancement of the 6F dilator catheter, a triple-lumen needle-knife with a 7F shaft diameter or a cystotome is gently inserted over the guide wire to dilate the tract using a brief burst of pure cutting current. A plastic stent or an expandable metal stent is then transgastrically deployed into the left intrahepatic system ( Figs. 2 and 3 ).
Related posts:
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Endoscopic Ultrasonography-Guided Biliary Drainage: Rendezvous Technique
Endoscopic Ultrasound Image Enhancement Elastography
Endoscopic Ultrasound: Contrast Enhancement
Endoscopic Ultrasonography-Guided Tumor Ablation
Endoscopic Ultrasonography-Guided Pancreatic Drainage
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