• acute cholecystitis
• endoscopic
• endoscopic retrograde cholangiopancreatography
• endoscopic ultrasound
• endoscopic ultrasound-guided gallbladder drainage
• obstructive jaundice
• ultrasound-guided biliary drainage

• ERCP
• EUS-guided antegrade stenting
• EUS-guided biliary drainage
• EUS-guided choledochoduodenostomy
• EUS-guided hepaticogastrostomy
• EUS-guided rendezvous technique
• Preoperative biliary drainage
• endoscopic transpapillary biliary drainage

• Humans
• Cholangiopancreatography, Endoscopic Retrograde
• Cholestasis/diagnostic imaging
• Cholestasis/etiology
• Cholestasis/surgery
• Drainage/methods
• Endosonography
• Jaundice, Obstructive/diagnostic imaging
• Jaundice, Obstructive/etiology
• Jaundice, Obstructive/surgery
• Stents
• Ultrasonography, Interventional/methods

• advanced inoperable malignancy
• drainage interventional ultrasound
• obstructive jaundice

• Adverse event
• Choledochoduodenostomy
• Endosonography
• Hepaticogastrostomy
• Indication

• Drainage
• Endoscopy
• Endosonography
• Humans
• Stents
• Treatment Outcome
• Ultrasonography, Interventional

Concomitant malignant gastric outlet obstruction and biliary obstruction may occur in patients with advanced cancers affecting these anatomical regions. This scenario presents a unique challenge to the endoscopist in selecting an optimal management approach. We sought to determine the efficacy and safety of endoscopic techniques for treating simultaneous gastric outlet and biliary obstruction (GOBO) with endoscopic ultrasound (EUS) guidance for biliary drainage. An extensive literature search for peer-reviewed published cases yielded 6 unique case series that either focused on or included the use of EUS-guided biliary drainage (EUS-BD) with simultaneous gastroduodenal stenting. In our composite analysis, a total of 51 patients underwent simultaneous biliary drainage through EUS, with an overall reported technical success rate of 100% for both duodenal stenting and biliary drainage. EUS-guided choledochoduodenostomy or EUS-guided hepaticogastrostomy was employed as the initial technique. In 34 cases in which clinical success was ascribed, 100% derived clinical benefit. The common adverse effects of double stenting included cholangitis, stent migration, bleeding, food impaction, and pancreatitis. We conclude that simultaneous double stenting with EUS-BD and gastroduodenal stenting for GOBO is associated with high success rates. It is a feasible and practical alternative to percutaneous biliary drainage or surgery for palliation in patients with associated advanced malignancies.

• Biliary tract
• Duodenal obstruction
• Endoscopy, digestive system
• Gastrointestinal neoplasms
• Ultrasonography, interventional

Endoscopic ultrasound/ultrasonography‐guided biliary drainage (EUS‐BD) is a relatively new modality for biliary drainage after failed or difficult transpapillary biliary cannulation. Despite its clinical utility, EUS‐BD can be complicated by severe adverse events such as bleeding, perforation, and peritonitis. The aim of this paper is to provide practice guidelines for safe performance of EUS‐BD as well as safe introduction of the procedure to non‐expert centers. The guidelines comprised patient–intervention–comparison–outcome‐formatted clinical questions (CQs) and questions (Qs), which are background statements to facilitate understanding of the CQs. A literature search was performed using the PubMed and Cochrane Library databases. Statement, evidence level, and strength of recommendation were created according to the GRADE system. Four committees were organized: guideline creation, expert panelist, evaluation, and external evaluation committees. We developed 13 CQs (methods, device selection, supportive treatment, management of adverse events, education and ethics) and six Qs (definition, indication, outcomes and adverse events) with statements, evidence levels, and strengths of recommendation. The guidelines explain the technical aspects, management of adverse events, and ethics of EUS‐BD and its introduction to non‐expert institutions.

• Biliary stricture
• EUS-guided biliary drainage
• Endoscopic ultrasonography
• Interventional EUS

• Biliary drainage
• Choledochoduodenostomy
• Endoscopic ultrasound
• Hepaticogastrostomy
• Rendezvous procedure
• Therapeutic endoscopic ultrasound

Over the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde cholangiopancreaticography (ERCP). The available evidence suggests that, in experienced hands, EUS-BD might even replace ERCP as the first-line procedure in specific situations such as malignant distal bile duct obstruction. The aim of this review is to summarize the available data on EUS-BD and propose an evidence-based algorithm clarifies the role of the different EUS-BD techniques in the management of benign and malignant biliary obstructive disease.

• Endoscopic ultrasound
• Endoscopic retrograde cholangiopancreaticography
• Biliary drainage
• Rendez-vous
• Hepaticogastrostomy
• Choledochoduodenostomy

• Biliary drainage
• biliary obstruction
• choledochoduodenostomy
• endoscopy-guided
• hepaticogastrostomy

• Adenocarcinoma/complications
• Aged
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholestasis, Extrahepatic/etiology
• Cholestasis, Extrahepatic/surgery
• Common Bile Duct Neoplasms/complications
• Drainage/adverse effects
• Drainage/instrumentation
• Drainage/methods
• Endosonography/adverse effects
• Female
• Humans
• Lymphatic Metastasis
• Male
• Middle Aged
• Operative Time
• Pancreatic Ducts
• Pancreatic Neoplasms/complications
• Prospective Studies
• Prosthesis Failure
• Stents/adverse effects
• Treatment Outcome
• Ultrasonography, Interventional/adverse effects

• Cholangitis
• Drainage
• Endoscopic retrograde cholangiopancreatography
• Endoscopic sphincterotomy
• Gallstones

To evaluate the efficacy of a newly developed dilator for endoscopic ultrasound (EUS)-guided drainage (ES Dilator).

Fourteen consecutive patients who had undergone EUS-guided choledochoduodenostomy (EUS-CDS) with the ES Dilator were identified from a prospectively maintained database and enrolled in the study group. Fourteen other patients who had undergone EUS-CDS without the dilator just prior to its introduction were analyzed as the control group. A historical cohort study was carried out comparing the two groups. The main outcome measurement was the procedure time. The technical success rate and early AE rate were also compared between the two groups.

There were no significant differences in age, sex and etiology of biliary obstruction. The utilization rate of a plastic stent was higher in the control group (36% vs 0%). The technical success rate was 100% in both groups. The mean procedure time was significantly shorter in the study group than in the control group (27 ± 7 min vs 44 ± 26 min, P = 0.026). Additionally, there were no patients who required more than 40 min for the procedure in the study group. Early adverse events occurred in 29% (4/14) of the control group whereas none in the study group. The adverse events in all 4 patients was bile peritonitis, including pan-peritonitis in one patient. All patients recovered with conservative treatment by medication.

The newly developed dilator was found to be useful for shortening procedure time and would prevent adverse events related to bile leakage in EUS-CDS.

• Endoscopic ultrasound
• Dilation
• Adverse event
• ES Dilator
• Cautery

• endoscopic ultrasonography (EUS)
• endosonography
• future
• interventional
• tissue acquisition

• Biliary Tract Obstruction
• ERCP
• Endoscopic Ultrasound
• Percutaneous Transhepatic Biliary Drainage

• Abdominal Pain/epidemiology
• Biliary Tract Surgical Procedures/methods
• Cholangitis/epidemiology
• Choledochostomy/methods
• Cholestasis/surgery
• Drainage/methods
• Endosonography
• Humans
• Odds Ratio
• Peritonitis/epidemiology
• Pneumoperitoneum/epidemiology
• Postoperative Complications/epidemiology
• Postoperative Hemorrhage
• Prosthesis Failure
• Surgery, Computer-Assisted/methods
• Treatment Outcome

• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasound
• Endoscopic ultrasound–guided anterograde cholangiopancreatography
• Pancreaticobiliary access

• Bile Ducts/diagnostic imaging
• Bile Ducts/surgery
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Drainage/methods
• Duodenum/diagnostic imaging
• Duodenum/surgery
• Endosonography/methods
• Humans
• Pancreatic Ducts/diagnostic imaging
• Pancreatic Ducts/surgery
• Stomach/diagnostic imaging
• Stomach/surgery

Endoscopic ultrasound (EUS) is clinically useful not only as a diagnostic tool during EUS-guided fine needle aspiration, but also during interventional EUS. EUS-guided biliary drainage has been developed and performed by experienced endoscopists. EUS-guided choledocoduodenostomy (EUS-CDS) is relatively well established as an alternative biliary drainage method for biliary decompression in patients with biliary obstruction. The reported technical success rate of EUS-CDS ranges from 50% to 100%, and the clinical success rate ranges from 92% to 100%. Further, the over-all technical success rate was 93%, and clinical success rate was 98%. Based on the currently available literature, the overall adverse event rate for EUS-CDS is 16%. The data on the cumulative technical and clinical success rate for EUS-CDS is promising. However, EUS-CDS can still lead to several problems, so techniques or devices that are more feasible and safe need to be established. EUS-CDS has the potential to become a first-line biliary drainage procedure, although standardizing the technique in multicenter clinical trials and comparisons with endoscopic biliary drainage by randomized clinical trials are still needed.

• Endoscopic ultrasound
• Endoscopic ultrasound-guided choledochoduodenostomy
• Endoscopic ultrasound-guided biliary drainage
• Percutaneous transhepatic biliary drainage

• Choledochostomy/adverse effects
• Choledochostomy/instrumentation
• Choledochostomy/methods
• Cholestasis/diagnosis
• Cholestasis/therapy
• Decompression/adverse effects
• Decompression/instrumentation
• Decompression/methods
• Drainage/adverse effects
• Drainage/instrumentation
• Drainage/methods
• Endoscopes, Gastrointestinal
• Endoscopy, Digestive System
• Endosonography/instrumentation
• Equipment Design
• Humans
• Patient Selection
• Predictive Value of Tests
• Risk Factors
• Treatment Outcome
• Ultrasonography, Interventional/instrumentation

• Biliary drainage
• Consortium
• Endoscopic ultrasound
• Endoscopic ultrasound-guided
• Endoscopic ultrasound-guided biliary drainage
• Pancreatic drainage

• Biliary Tract Diseases/diagnostic imaging
• Biliary Tract Diseases/therapy
• Choledochostomy/adverse effects
• Choledochostomy/methods
• Choledochostomy/standards
• Decompression/adverse effects
• Decompression/methods
• Decompression/standards
• Drainage/adverse effects
• Drainage/methods
• Drainage/standards
• Endosonography/standards
• Gastrostomy/adverse effects
• Gastrostomy/methods
• Gastrostomy/standards
• Humans
• Pancreatic Diseases/diagnostic imaging
• Pancreatic Diseases/therapy
• Practice Guidelines as Topic
• Predictive Value of Tests
• Treatment Outcome
• Ultrasonography, Interventional/standards

• Bile duct
• Biliary drainage
• Endoscopic retrograde cholangio-pancreatography
• Endoscopic ultrasound
• Pancreatic drainage
• Pancreatic duct
• Percutaneous transhepatic cholangiography

• biliary drainage
• choledocho
• endoscopic ultrasound-guided

Endoscopic retrograde cholangiography (ERCP) is widely used as a first-line therapy for biliary drainage. ERCP occasionally fails owing to anatomical or technical problems, despite high reported success rates. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has recently emerged as an effective alternative biliary drainage method after unsuccessful ERCP. EUS-BD can be essentially divided into 3 different techniques—(1) EUS-guided transluminal biliary drainage including choledocoduodenostomy and hepaticogastrostomy, (2) EUS-rendezvous technique, and (3) EUS-antegrade approach. Here, we focus on the current status of EUS-BD in light of these 3 different techniques.

• Antegrade
• Biliary drainage
• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasound
• Rendezvous

Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

• Biliary stricture
• Cholangiopancreatography, endoscopic retrograde
• Endoscopic ultrasound guided biliary drainage
• Endosonography

AIM: To describe a successful endoscopic ultrasound (EUS)-guided biliary drainage technique with high success and low complication rates.

METHODS: The recorded data of consecutive patients who presented to Siriraj Gastrointestinal Endoscopy Center, Siriraj Hospital in Bangkok, Thailand for treatment of malignant obstructive jaundice but failed endoscopic retrograde cholangiopancreatography and underwent subsequent EUS-guided biliary drainage were retrospectively reviewed. The patients’ baseline characteristics, clinical manifestations, procedure details, and post-procedure follow-up data were recorded and analyzed. Clinical outcomes were assessed by physical exam and standard laboratory tests. Technical success of the procedure was defined as completion of the stent insertion. Clinical success was defined as improvement of the patient’s overall clinical manifestations, in terms of general well-being evidenced by physical examination, restoration of normal appetite, and adequate biliary drainage. Overall median survival time was calculated as the time from the procedure until the time of death, and survival analysis was performed by the Kaplan-Meier method. The Student’s t-test and the χ² test were used to assess the significance of inter-group differences.

RESULTS: A total of 21 cases were enrolled, a single endoscopist performed all the procedures. The mean age was 62.8 years (range: 46-84 years). The sex distribution was almost equal, including 11 women and 10 men. Patients with failed papillary cannulation (33.3%), duodenal obstruction (42.9%), failed selective cannulation (19.0%), and surgical altered anatomy (4.8%) were considered candidates for EUS-guided biliary drainage. Six patients underwent EUS-guided choledochoduodenostomy and 15 underwent EUS-guided hepaticogastrostomy. The technique using non-cauterization and no balloon dilation was performed for all cases, employing the in-house manufactured tapered tip Teflon catheter to achieve the dilation. The technical success and clinical success rates of this technique were 95.2% and 90.5%, respectively. Complications included bile leakage and pneumoperitoneum, occurred at a rate of 9.5%. None of the patients died from the procedure. One patient presented with a biloma, a major complication that was successfully treated by another endoscopic procedure.

CONCLUSION: We present a highly effective EUS-guided biliary drainage technique that does not require cauterization or balloon dilation.

• Endoscopic ultrasound
• Biliary drainage
• Hepaticogastrostomy
• Choledochoduodenostomy
• Endoscopic ultrasound-guided

• Aged
• Aged, 80 and over
• Chi-Square Distribution
• Cholangiopancreatography, Endoscopic Retrograde
• Cholestasis/diagnosis
• Cholestasis/etiology
• Cholestasis/mortality
• Cholestasis/surgery
• Drainage/adverse effects
• Drainage/instrumentation
• Drainage/methods
• Drainage/mortality
• Endosonography/adverse effects
• Endosonography/instrumentation
• Endosonography/mortality
• Female
• Humans
• Jaundice, Obstructive/diagnosis
• Jaundice, Obstructive/etiology
• Jaundice, Obstructive/mortality
• Jaundice, Obstructive/surgery
• Kaplan-Meier Estimate
• Male
• Middle Aged
• Retrospective Studies
• Stents
• Thailand
• Time Factors
• Treatment Outcome

• EUS
• PTBD
• biliary drainage
• biliary stenting
• choledocho-duodenostomy
• hepatico-gastrostomy
• interventional EUS
• therapeutic endosonography

Endoscopic retrograde cholangiopancreatography (ERCP) can fail in 3–10% of the cases even in experienced hands. Although percutaneous transhepatic cholangiography (PTC) and surgery are the traditional alternatives, there are morbidity and mortality associated with both. In this paper, we have discussed the efficacy and safety of endoscopic-ultrasound-guided cholangiopancreatography (EUS-CP) in decompression of biliary and pancreatic ducts. The overall technical and clinical success rates are around 90% for biliary and 70% for pancreatic duct drainage. The overall EUS-CP complication rate is around 15%. EUS-CP is, however, a technically challenging procedure and should be performed by an experienced endoscopist skilled in both EUS and ERCP. Same session EUS-CP as failed initial ERCP is practical and may result in avoidance of additional procedures. With increasing availability of endoscopists trained in both ERCP and EUS, the role of EUS-CP is likely to grow in clinical practice.

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7^th, 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting’s agenda and the conclusions generated by the creation of this consortium group.

• Endoscopic ultrasound
• Biliary drainage
• Endosonography-guided cholangiopancreatography
• Endoscopic ultrasound guided
• Pancreatic drainage
• Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) has become the first-line therapy for bile duct drainage. In the hands of experienced endoscopists, conventional ERCP results in a failed cannulation rate of 3% to 5%. This failure can occur more commonly in the setting of altered anatomy or technically difficult cases due to either duodenal or biliary obstruction. In cases of ERCP failure, patients have traditionally been referred for either percutaneous transhepatic biliary drainage (PTBD) or surgery. However, both PTBD and surgery have higher than desirable complication rates. Within the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an attractive alternative to PTBD after failed ERCP. Many groups have reported on the feasibility, efficacy and safety of this technique. This article reviews the indications for ERCP and the currently practiced EUS-BD techniques, including EUS-guided rendezvous, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy.

• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasound
• Self expanding metal stent

AIM: To investigate the long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with a fully covered self-expandable metallic stent (FCSEMS).

METHODS: From April 2009 to August 2010, 15 patients with distal malignant biliary obstructions who were candidates for alternative techniques for biliary decompression due to a failed endoscopic retrograde cholangiopancreatography (ERCP) were included. These 15 patients consisted of 8 men and 7 women and had a median age of 61 years (range: 30-91 years). The underlying causes of the distal malignant biliary obstruction were pancreatic cancer (n = 9), ampulla of Vater cancer (n = 2), renal cell carcinoma (n = 1), advanced gastric cancer (n = 1), lymphoma (n = 1), and duodenal cancer (n = 1).

RESULTS: The technical success rate of EUS-CDS with an FCSEMS was 86.7% (13/15), and functional success was achieved in 100% (13/13) of those cases. In two patients, the EUS-CDS failed because an FCSEMS with a delivery device could not be passed into the common bile duct. The mean duration of stent patency was 264 d. Early adverse events developed in three patients (3/13, 23.1%), including self-limited pneumoperitoneum in two patients and cholangitis requiring stent reposition in one patient. During the follow-up period (median: 186 d, range: 52-388 d), distal stent migration occurred in four patients (4/13, 30.8%). In 3 patients, the FCSEMS could be reinserted through the existing choledochoduodenal fistula tract.

CONCLUSION: EUS-CDS with an FCSEMS is technically feasible and can lead to effective palliation of distal malignant biliary obstructions after failed ERCP.

• Bile duct obstruction
• Drainage
• Endosonography
• Self-expandable metallic stent
• Neoplasms