EUS-Guided Bilio-Pancreatic Drainage

Abstract

EUS-guided biliary drainage is an option to treat obstructive jaundice when ERCP drainage fails. This procedure is an alternative to surgical and percutaneous transhepatic biliary drainage, and only possible with the continuous development and improvement of EUS scopes and accessories. The development of linear array EUS scopes in the early 1990s brought a new approach to diagnostics and a therapeutic dimension to EUS capabilities, opening the possibility to perform punctures under direct EUS guidance. Despite the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty can occur in the presence of stent tumor ingrowth, tumor obstructing the intestinal lumen, periampullary diverticula and anatomic variation. The EUS technique starts with performing the puncture and contrast injection of the left biliary tree. From the duodenum, a direct common bile duct puncture is performed. Dilatation of the punctured tract is required using a bougie or balloon dilator and a plastic or metallic stent is introduced. The technical success of hepaticogastrostomy is near 98 %, and complications occur in 20 %. To prevent bile leakage we have used the 2 stent technique: the first stent introduced is a long uncovered metallic stent (8 or 10 cm) and a second fully covered stent (6 cm) is deployed within the first stent to bridge the bile duct and the stomach. The overall success rate of choledochoduodenostomy is 92 % with complications in 14 %. Over the last 10 years, this technique has been mainly performed in referral centers by groups experienced in ERCP, and this seems to be a general guideline for safer execution of this procedure.