EUS-guided biliary drainage

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Endoscopic ultrasound (EUS)-guided biliary drainage is an alternative to conventional transpapillary and percutaneous biliary drainage in where an extra-anatomic route is created between the biliary tree and the gastrointestinal tract.

Indications

  • failed endoscopic transpapillary biliary drainage 
    • altered anatomy (e.g. pancreatoduodenectomy)
  • failed percutaneous transhepatic biliary drainage
  • history of severe pancreatitis linked to previous transpapillary approach 
    • there is much less risk of pancreatitis on the EUS technique as the papilla of Vater is usually not manipulated

Procedure

Preprocedural evaluation

Review of prior imaging with regards to the type of biliary stricture (Bismuth classification) is required to assess the best extra-anatomical route of drainage. This also takes into consideration the portal vein patency, liver volume, and sites of focal cholangitis .

Equipment
  • plastic stent
  • covered metallic stent 
    • preferable to reduce the risk of bile leakage
Technique

Extra-anatomical routes in between the biliary tree and the gastrointestinal tract include :

  • hepaticogastrostomy
    • preferable method to be performed in combination with a duodenal stent placement
  • choledochoduodenostomy
    • in distal biliary stricture not extending to the hilar region
  • hepaticojejunostomy
    • preferable in patients with previous gastrectomy and esophageal-jejunal anastomosis 
  • hepaticoduodenostomy
    • technically very challenging procedure used in complicated biliary strictures (Bismuth II-IV)
  • endoscopic US-guided gallbladder drainage  
    • equivalent to the percutaneous cholecystostomy but with a higher risk of biliary peritonitis
    • usually applied as a final and more comfortable longterm solution than the percutaneous cholecystostomy in patients that are not a candidate for surgery

Complications

Although dependent on the skills of the operator, these techniques have been reported with high technical and functional success on the hands of experienced endoscopists, usually in tertiary centers .

Possible complications include :

  • stent migration 
    • early
    • delayed: migration occurs after the formation of a tract between the biliary tree and GI tract 
  • stent malpositioning: gastrointestinal end of the stent pointed towards the afferent stomach or small bowel loop can lead to food impaction into the stent and, therefore, be at risk for obstruction or cholangitis 
  • bile leak
  • cholangitis and liver abscess
  • bleeding
    • hematoma 
    • pseudoaneurysm
  • stent obstruction/malfunction 
  • focal new biliary dilatation due to stent block of adjacent segmental bile ducts 
  • portobiliary fistula (rare )

Outcomes

  • biliary tree decompression and symptoms relief