Decompression of malignant biliary obstruction after failed ERCP: to EUSBD and not to PTBD?

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Although endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage is the most common procedure used to palliate patients with malignant biliary obstruction, it is unsuccessful in 3–10 % of cases [1, 2]. Failure occurs due to operator inexperience, anatomic variation, tumor extension, prior surgery, and/or incomplete drainage [3, 4]. Percutaneous transhepatic biliary drainage (PTBD) or surgical bypass is often employed after failed ERCP but is associated with a higher morbidity and mortality [3, 5]. Recently, endoscopic ultrasound-guided biliary drainage (EUSBD) has been used as an alternative for patients with failed ERCP. Since it was first described in 2001 by Giovannini et al. [6], many reports have been published focusing on its indications, technique modifications, and efficacy. There is, however, a paucity of literature regarding comparison of EUSBD and PTBD. EUSBD may have advantages over PTBD including avoidance of vascular injury, lack of interference by ascites, and internal drainage within a single session [3, 4, 6, 7]. Moreover, EUSBD can be successfully performed even in patients who have undergone total gastrectomy or partial gastrectomy with a Billroth II reconstruction. EUSBD procedures exist in three categories—(1) EUS-guided transluminal biliary drainage including choledochoduodenostomy (EUS-CD) and hepaticogastrostomy (EUS-HG), (2) EUS-rendezvous technique (EUS-RV), and (3) EUSantegrade approach (EUS-AG) [8]. In EUS-guided transluminal biliary drainage, after visualizing the dilated biliary duct under EUS guidance, a fistula is created between upper intestine and bile duct. The fistula is dilated, and stent is deployed for biliary drainage. This technique is divided further into hepaticogastrostomy (HGS), in which the fistula is made between the stomach and intrahepatic bile duct (IHBD) of the left lobe, and choledochoduodenostomy (CDS), in which the fistula is created between the duodenal bulb and extrahepatic bile duct (EHBD). Covered metal stents (CMS) are preferred over plastic stents to minimize biliary leak and pneumoperitoneum. Yet, stent migration is a serious complication that can occur shortly after stent deployment. In the EUS-rendezvous technique, the biliary duct is accessed under EUS and fluoroscopic guidance and a fistula is created followed by guidewire placement via the biliary duct and ampulla into the duodenum. With the help of the rendezvous technique, biliary cannulation is achieved. EUS-RV should be attempted for patients with an endoscopically accessible ampulla after failed ERCP. EUS-RV can be divided into IHBD and EHBD approaches. Kahaleh et al. [4] reported a lower risk of biliary leak with the IHBD approach, as compared to the EHBD approach. Theoretically, the IHBD approach may reduce the risk of bile leakage because the liver parenchyma around the bile duct can tamponade the fistula. Nevertheless, the success rate is the most important factor, as proper biliary drainage can reduce bile leakage and treat bile peritonitis. With EUS-guided antegrade drainage, the IHBD is accessed from the upper intestine with creation of a temporary fistula between the intestine and IHBD. After dilation of the fistula, a self-expanding metal stent (SEMS) is deployed across biliary obstruction in an antegrade fashion. Although this technique is suitable for biliary obstruction in patients with surgically altered anatomy or with upper intestinal obstruction where endoscopic access to the ampulla is not possible, the selection of EUS-BD techniques is more complex: EUS-RV can be a first-line EUS-BD technique in patients with an endoscopically V. Singh (&) Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India e-mail: virendrasingh100@hotmail.com