Endoscopic Ultrasound-Guided Biliary Drainage: History
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John B. Doyle
,
Amrita Sethi

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are currently first- and second-line therapeutic options, respectively, for the relief of biliary obstruction. However, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an established alternative therapy for biliary obstruction. There are multiple different techniques for EUS-BD, which can be distinguished based on the access point within the biliary tree (intrahepatic versus extrahepatic) and the location of stent placement (transenteric versus transpapillary). The clinical and technical success rates of biliary drainage for EUS-BD are similar to both ERCP and PTBD, and complication rates are favorable for EUS-BD relative to PTBD.

  • endoscopic ultrasound
  • biliary obstruction
  • choledochoduodenostomy

1. Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is currently the first-line therapeutic option for the relief of benign and malignant biliary obstruction [1]. During ERCP, a side-viewing duodenoscope is used to cannulate the ampulla of Vater, through which the biliary tree and pancreatic duct can be accessed for dilation or stent placement. However, ERCP is unsuccessful in relieving biliary obstruction in 5–10% of cases [2][3]. This is often due to anatomical abnormalities or post-surgical changes that render cannulating the ampulla either difficult or impossible.
For decades, the second-line therapeutic intervention for biliary drainage following a failed ERCP has been percutaneous transhepatic biliary drainage (PTBD). In PTBD, the biliary system is accessed via a cutaneous incision, and biliary obstruction is relieved by an external biliary drain [4]. PTBD can have notable complications, including bacteremia, hemobilia, and the dislodgement, occlusion, or leakage of the external biliary drain [5][6][7]. Relative to internal enteric biliary drainage, the presence of an external biliary catheter that is required in PTBD can also lead to frequent bag exchanges, skin irritation, and reduced quality of life [8][9][10].
In recent years, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been recognized as an appealing alternative to PTBD to relieve biliary obstruction after failed ERCP.

2. EUS-BD

At present, EUS-BD is most commonly indicated for patients with malignant obstruction of the distal biliary tree when ERCP is unsuccessful or not feasible. This is often due to anatomical pathology, which makes it difficult or impossible to cannulate the papilla with a side-viewing duodenoscope, including gastric outlet obstruction, duodenal stenosis, ampullary tumor, or periampullary diverticulum. In addition, EUS-BD is useful for patients with surgically-altered anatomy, particularly following surgeries such as Roux-en-Y gastric bypass, Roux-en-Y hepaticojejunostomy, pancreaticoduodenectomy, or partial gastrectomy, in which access to the ampulla is technically cumbersome [11][12]. EUS-BD has also been used in patients with existing gastroduodenal stents that obstruct ampullary access [13].

2.1. EUS-Guided Hepaticogastrostomy (EUS-HGS)

In this technique, an echoendoscope is positioned in the gastric body to provide the ultrasound visualization of the left intrahepatic bile ducts [14][15][16][17]. Under this ultrasound visualization, a needle is used to access the intrahepatic biliary ducts, and a color doppler is used to identify and avoid any intervening vasculature. After needle access is obtained, a cholangiogram is performed to confirm biliary access and delineate biliary anatomy. A guidewire is then advanced through the needle and into the intrahepatic duct and biliary tree. After dilation, a stent can be deployed over the guidewire to create a hepaticogastrostomy and allow bile drainage directly into the stomach lumen.
EUS-HGS is particularly useful for patients with a gastroduodenal obstruction or post-surgical anatomy, including patients with prior pancreaticoduodenectomy or Roux-en-Y hepaticojejunostomy [14]. Given that EUS-HGS techniques typically involve access to the dilated left intrahepatic biliary ducts, the utility of EUS-HGS may be more limited in patients without intrahepatic ductal dilation or with only a right-sided intrahepatic biliary obstruction [16]. Relative contraindications include coagulopathy, massive ascites, and stomach wall pathology, such as a tumor or ulceration [14]. The most common complications of EUS-HGS include infection (including cholangitis, pancreatitis, and biliary peritonitis), bleeding, and bile leaks.

2.2. EUS-Guided Choledochoduodenostomy (EUS-CDS)

In EUS-CDS, an echoendoscope is positioned in the duodenal bulb, and a needle is placed into the extrahepatic biliary tree under direct ultrasound guidance. In a similar fashion to the EUS-HGS technique, a contrast is then injected to obtain a cholangiogram, and a guidewire is inserted into the common hepatic duct or the common biliary duct. A fistulous tract is created with cautery or dilation, and a stent is deployed [15][16][17]. The result is a transduodenal stent draining the extrahepatic biliary tree, as opposed to EUS-HGS, which results in a transgastric stent draining the intrahepatic biliary tree.
EUS-CDS can be a useful technique for biliary drainage in patients with distal malignant biliary obstruction due to periampullary malignancy and mass or papillary stenosis. It has similar complications and contraindications to EUS-HGS. If performed in the setting of a pending or existing duodenal obstruction, then adequate bile drainage needs to be established, either with a duodenal stent or a gastrojejunostomy, which can be performed endoscopically at the time of EUS-CDS.

2.3. EUS-Guided Antegrade Stent Placement

While EUS-HGS and EUS-CDS both involve transenteric stenting and biliary drainage, EUS-guided antegrade stent placement is a technique that can achieve transpapillary biliary stenting. In this technique, either intrahepatic or extrahepatic access is created via the gastric or duodenal lumen under ultrasound guidance, as described above. Once the biliary tree is accessed, a guidewire can be used to traverse the biliary obstruction and the ampulla [14][15]. Contrast can be injected to confirm extravasation into the small bowel to ensure proper placement, and if confirmed, a transpapillary stent can be placed in the antegrade fashion. This technique requires that a guidewire is able to pass distally to the obstructed biliary tree.
EUS-guided antegrade stent placement has a theoretical advantage over EUS-HGS or EUS-CDS in that it can avoid the creation of a new anastomosis at the biliary access site and any consequent adverse events [11]. EUS-guided antegrade stent placement can be especially useful in patients with surgically-altered anatomies, such as the Roux-en-Y gastric bypass, and who have preserved ampullary anatomy and physiology. With a transpapillary stent, however, there is a higher risk of pancreatitis or cholangitis that is relative to EUS-HGS or EUS-CG [11].

2.4. EUS-Guided Rendezvous Technique

In the EUS-guided rendezvous technique, extrahepatic or intrahepatic access can be obtained using the echoendoscope and the methods described above. Similar to EUS-guided antegrade stent placement, this technique requires that once biliary access is obtained and a guidewire is placed across the biliary obstructions and into the ampulla. The guidewire is then left in place, and a duodenoscope is maneuvered to the second portion of the duodenum; the wire is used to facilitate ampullary cannulation, and a conventional ERCP can then be performed.
As with the EUS-guided antegrade stent placement, this achieves transpapillary drainage without transluminal anastomosis at the biliary access site [11][16][17]. This rendezvous technique can be useful when the second portion of the duodenum is accessible, but the conventional cannulation of the papilla is technically difficult [11][15][17].

3. Outcomes of EUS-BD

3.1. Efficacy and Adverse Events of EUS-BD

EUS-BD has a high technical and clinical success rate in relieving biliary obstruction, along with a favorable adverse event rate profile that is relative to alternative interventions. Much of the current literature has explored the role of EUS-BD after failed ERCP in the relief of MBO in particular. Systematic reviews and meta-analyses have demonstrated the technical and clinical success rates of EUS-BD to be 90–95% in this setting, respectively [8][16][18]. Meta-analyses have demonstrated procedure-related adverse event rates to be between 15 and 24%, with the most common complications being infection (including cholangitis, pancreatitis, and biliary peritonitis), bleeding, pneumoperitoneum, and bile leaks [8][16][18][19]. In EUS-HGS, a transesophageal puncture has also been reported, which can result in pneumothorax or mediastinitis [19].

3.2. EUS-BD vs. PTBD

Given that PTBD remains the conventional therapeutic intervention for biliary obstruction following failed ERCP, investigators have compared the outcomes between PTBD and EUS-BD [8][9][20][21][22][23]. Recent randomized controlled trials have found that EUS-BD and PTBD were equivalent in terms of the technical and clinical success of relieving biliary obstruction [20][23], and multiple retrospective studies and meta-analyses have demonstrated similar findings [8][9][21][22][24].

3.3. EUS-BD vs. ERCP as First-Line Intervention for Malignant Biliary Obstruction

Although EUS-BD is currently considered a second-line therapy after failed ERCP, several studies in recent years have compared EUS-BD to ERCP as the first-line intervention for biliary obstruction. The theoretical advantages of transenteric stenting (via EUS-HGS or EUS-CDS) relative to transpapillary stenting via ERCP include: the minimization of papillary manipulation leading to pancreatitis; the avoidance of stent tumor ingrowth which can occur when the stent is placed through a distal malignant biliary stricture; and the ability to access biliary ducts despite surgically-altered anatomy or gastroduodenal stents.

This entry is adapted from the peer-reviewed paper 10.3390/jcm12072736

References

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