EUS-Guided Biliary Drainage

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


  • 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.

May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on EUS-Guided Biliary Drainage

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