Endoscopic ultrasound-guided biliary drainage-current status and future perspectives

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction. ERCP could fail in cases of duodenal obstruction, duodenal diverticulum, ampullary neoplastic infiltration or surgically altered anatomy. In these cases percutaneous biliary drainage (PTBD) is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices. A large amount of data is already collected that proves its efficacy, safety and ability to replace PTBD in cases of ERCP failure. It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future. Several EUS-BD techniques are developed EUS-guided transmural stenting, antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy. EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure. The lack of training, absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure, which is related to life-threatening adverse events. Developing training models, dedicated devices and guidelines hopefully will make EUS-BD easier, safer and well accepted in the future. This paper focuses on the technical aspects of the different EUS-BD procedures, available literature data, advantages, negative aspects and the future perspectives of these modalities.

Keywords: Endoscopic ultrasound-guided biliary drainage, Malignant bile duct obstruction, Endoscopic ultrasound-guided hepaticogastrostomy, Endoscopic ultrasound-guided rendezvous technique, Endoscopic ultrasound-guided choledochoduodenostomy, Endoscopic ultrasound-guided antegrade stenting, Endoscopic retrograde cholangiopancreatography

Core Tip: Endoscopic retrograde cholangiopancreatography is the current standard of care for bile duct obstruction but is not always possible. The traditional rescue modality is percutaneous transhepatic biliary drainage which has many disadvantages. Endosonography-guided biliary drainage is a new promising interventional technique, showing many advantages over percutaneous biliary drainage and is able to fully replace it when the expertise is available. Developing new devices, training models and guidelines is expected to make this procedure easier, safe and widely accepted in the near future.