EUS-Guided Biliary Drainage
Woo Hyun Paik, MD, PhD
Do Hyun Park, MD, PhD
Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) has emerged as an alternative to percutaneous transhepatic biliary drainage (PTBD), particularly after failed endoscopic retrograde cholangiopancreatography (ERCP).1,2 EUS-BD has some advantages over ERCP and PTBD.3,4 ERCP is not technically feasible when the papilla is not endoscopically accessible, while EUS-BD is possible in surgically altered anatomy or inaccessible papilla. One of the most common adverse events of ERCP is postprocedure pancreatitis. In EUS-BD, papillary manipulation is avoided, thus eliminating the risk of acute pancreatitis. Stent patency may be longer in EUS-BD than in ERCP since the stents do not cross a stricture and instead reside in healthy tissue. When performed by experienced endoscopists, EUS-BD provides similar efficacy to PTBD and is more comfortable and physiologic because of avoidance of external drains and restoration of internal drainage. However, EUS-BD has not become widely adopted because of the complexity of the procedure and relative lack of dedicated devices and accessories.5
EUS-BD is classified into three categories: rendezvous technique, antegrade stenting, and transmural stenting.2 The EUS-BD approach taken is determined by accessibility to the duodenum and papilla. When the papilla is endoscopically accessible, the rendezvous technique may be preferred as an approach when ERCP and selective cannulation of the bile duct fail. However, guidewire manipulation traversing through the ampulla can be challenging. Antegrade stenting may be suitable when a guidewire can be passed through the papilla from an EUS transgastric intrahepatic approach. Antegrade stenting is useful especially when the papilla is inaccessible endoscopically. Transmural stenting is the most widely performed form of EUS-BD. Transmural stenting is performed in one of the two ways: EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy
(EUS-CDS). EUS-CDS may be technically easier than EUS-HGS. EUS-HGS has more adverse events than EUS-CDS, with potential risks of life-threatening adverse events including mediastinitis and pneumomediastinum.6 EUS-CDS is more likely to cause bile leak than EUS-HGS. In cases of surgically altered anatomy or duodenal obstruction, hepaticogastrostomy is preferred as the duodenum cannot be reached. In patients with acute cholecystitis and high risk of surgery, EUS-guided gallbladder drainage (EUS-GBD) may be considered. In addition, EUS-GBD can be used for decompression of malignant distal bile duct obstruction when ERCP fails and the biliary ducts proximal to the obstruction are not dilated.7
(EUS-CDS). EUS-CDS may be technically easier than EUS-HGS. EUS-HGS has more adverse events than EUS-CDS, with potential risks of life-threatening adverse events including mediastinitis and pneumomediastinum.6 EUS-CDS is more likely to cause bile leak than EUS-HGS. In cases of surgically altered anatomy or duodenal obstruction, hepaticogastrostomy is preferred as the duodenum cannot be reached. In patients with acute cholecystitis and high risk of surgery, EUS-guided gallbladder drainage (EUS-GBD) may be considered. In addition, EUS-GBD can be used for decompression of malignant distal bile duct obstruction when ERCP fails and the biliary ducts proximal to the obstruction are not dilated.7
INDICATIONS
1. Failed deep biliary cannulation during ERCP
2. Surgically altered anatomy
3. Duodenal obstruction or prior duodenal metal stent placement across the papilla
4. Unavailability of PTBD or refusal of PTBD and surgical bypass
CONTRAINDICATIONS
1. Patients with coagulopathy
2. Multifocal intrahepatic ductal obstruction
EQUIPMENT
1. Conventional EUS-guided fine needle aspiration needle (FNA) (usually 19-gauge) or novel needle for EUS-BD (EUS access needle, Cook Medical, Bloomington, USA); it has blunt needle tip that can prevent shearing of guidewires
2. A curvilinear array echoendoscope
3. Fluoroscopy system
4. A guidewire; a 0.025-inch VisiGlide guidewire (Olympus America, San Jose, USA) is preferred in EUS-BD because of its adequate stiffness and improved negotiation capability. 0.035-inch guidewires (Jagwire, Boston Scientific, Natick, USA; Tracer, Cook Medical) may be useful
5. Diluted contrast media
6. 4F cannula for difficult guidewire manipulation
7. Devices for fistula dilation: 4F cannula, 6F, and 7F bougie catheters, 4-mm balloon catheter (Hurricane RX, Boston Scientific), needle knife, and 6F cystotome (Cook Medical). The use of a needle knife for fistula dilation is not recommended for the risk of adverse events including pneumoperitoneum and bleeding8
8. Biliary stents: fully covered or partially covered self-expandable metal stents are superior to plastic stents in
preventing bile leak. To prevent stent migration, several types of metal stents with flared end, uncovered portion at the bile duct side, flaps, or flanges have been developed but are not available in the United States. Lumen-apposing metal stents (LAMSs) for EUS-CDS and EUS-GBD are commonly used (off-label). The addition of novel dedicated devices that combine electrocautery with a LAMS or a tapered metal tip introducer as a push-type dilator with a preloaded metallic stent for one-step EUS-BD without additional fistula dilation has been introduced, which can shorten procedural times and decrease procedure-related adverse events.9,10
PREPARATION
1. Obtain informed consent.
2. Administer prophylactic antibiotics before EUS-BD.
3. There is no consensus about fasting time in EUS-BD; however, we recommend fasting time as for other upper endoscopic procedures and per anesthesia guidelines.
4. EUS-BD can be performed under moderate/deep sedation or general anesthesia.
5. CO2 insufflation during the procedure is recommended to reduce the risk of pneumoperitoneum.
PROCEDURES
Rendezvous Technique
1. The extra- or intrahepatics are accessed with an EUS-FNA needle. The extrahepatic approach may be preferred because the intrahepatic approach requires more difficult guidewire manipulation that has to pass through the stricture site as well as the papilla. The extrahepatic bile duct can be assessed by two methods: push and pull methods. Although pull methods have a more unstable endoscope position than push methods, negotiation of guidewire across the papilla is easier with pull methods. The intrahepatics can be approached via puncture of liver segment 2 (B2) or segment 3 (B3). B2 duct is less angulated than B3 and is preferred (Fig. 33.1).
2. After puncturing the bile duct, aspiration is used to confirm bile duct access (Fig. 33.2A).
3. Contrast is injected to obtain cholangiography, and a guidewire is negotiated across the stricture and through the papilla in an antegrade manner. Coiling of the guidewire inside the duodenum is necessary to prevent loss of guidewire during withdrawal of the needle and the echoendoscope (Fig. 33.2B).Related posts:
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