Surgical Endoscopy

, Volume 25, Issue 2, pp 549–555

Endoscopic ultrasound-guided transduodenal placement of a fully covered metal stent for palliative biliary drainage in patients with malignant biliary obstruction

  • Ali A. Siddiqui
  • Jayaprakash Sreenarasimhaiah
  • Luis F. Lara
  • William Harford
  • Calvin Lee
  • Mohamad A. Eloubeidi



Endoscopic ultrasound (EUS)-guided biliary drainage (EUSBD) has been described as a viable alternative to percutaneous transhepatic cholangiography (PTC) in patients in whom ERCP has been unsuccessful. The purpose of our study was to assess the utility of EUSBD using a newly released, fully covered, self-expanding, biliary metal stent (SEMS) for palliation in patients with an obstructing malignant biliary stricture.


We collected data on all patients who presented with obstructive jaundice and who underwent transduodenal EUSBD after a failed ERCP. Eight patients presented with biliary obstruction from inoperable pancreatic cancer or cholangiocarcinoma. Reasons for failed ERCP were duodenum stenosis, high-grade malignant stenosis of the common bile duct, periampullary tumor infiltration, failure to access the common bile duct, and periampullary diverticulum. EUS was used to access the common bile duct from the duodenum after which a guidewire was advanced upwards toward the liver hilum. The metal stent was then advanced into the biliary tree. Technical success was defined as correct stent deployment across the duodenum. Clinical success was defined as serum bilirubin level decreased by 50% or more within 2 weeks after the stent placement.


Technical and clinical success was achieved in all eight patients. No stent malfunction or occlusion was observed. Complications included one case of duodenal perforation, which required surgery, and one case of self-limiting abdominal pain.


EUSBD with a fully covered SEMS in whom ERCP is unsuccessful is effective for palliation of biliary obstruction. The limitations of our study are that we had a small number of patients and a limited follow-up time.


Pancreato Bilio Cancer Digestive Instruments Technical Ultrasonography G-I Endoscopy 


  1. 1.
    Fogel EL, Sherman S, Devereaux BM, Lehman GA (2001) Therapeutic biliary endoscopy. Endoscopy 33:31–38CrossRefPubMedGoogle Scholar
  2. 2.
    Vitale GC, George M, McIntyre K, Larson GM, Wieman TJ (1996) Endoscopic management of benign and malignant biliary strictures. Am J Surg 171:553–557CrossRefPubMedGoogle Scholar
  3. 3.
    Carr-Locke DL (2002) Overview of the role of ERCP in the management of diseases of the biliary tract and the pancreas. Gastrointest Endosc 56:S157–S160CrossRefPubMedGoogle Scholar
  4. 4.
    Schofl R (2001) Diagnostic endoscopic retrograde cholangiopancreatography. Endoscopy 33:147–157CrossRefPubMedGoogle Scholar
  5. 5.
    Kumar S, Sherman S, Hawes RH, Lehman GA (1995) Success and yield of second attempt ERCP. Gastrointest Endosc 41:445–447CrossRefPubMedGoogle Scholar
  6. 6.
    Lobo DN, Balfour TW, Iftikhar SY (1998) Periampullary diverticula: consequences of failed ERCP. Ann R Coll Surg Engl 80:326–331PubMedGoogle Scholar
  7. 7.
    Martin DF (1994) Combined percutaneous and endoscopic procedures for bile duct obstruction. Gut 35:1011–1012CrossRefPubMedGoogle Scholar
  8. 8.
    Harbin WP, Mueller PR, Ferrucci JT Jr (1980) Transhepatic cholangiography: complications and use patterns of the fine-needle technique: a multi-institutional survey. Radiology 135:15–22PubMedGoogle Scholar
  9. 9.
    Doctor N, Dick R, Rai R, Dafnios N, Salamat A, Whiteway H, Dooley J, Davidson BR (1999) Results of percutaneous plastic stents for malignant distal biliary obstruction following failed endoscopic stent insertion and comparison with current literature on expandable metallic stents. Eur J Gastroenterol Hepatol 11:775–780CrossRefPubMedGoogle Scholar
  10. 10.
    Beissert M, Wittenberg G, Sandstede J, Beer M, Tschammler A, Burghardt W, Jahns R, Hahn D (2002) Metallic stents and plastic endoprostheses in percutaneous treatment of biliary obstruction. Z Gastroenterol 40:503–510CrossRefPubMedGoogle Scholar
  11. 11.
    Yee AC, Ho CS (1987) Complications of percutaneous biliary drainage: benign vs malignant diseases. AJR Am J Roentgenol 148:1207–1209PubMedGoogle Scholar
  12. 12.
    Ang TL, Teo EK, Fock KM (2007) EUS-guided transduodenal biliary drainage in unresectable pancreatic cancer with obstructive jaundice. JOP 8:438–443PubMedGoogle Scholar
  13. 13.
    Irisawa A, Hikichi T, Shibukawa G, Takagi T, Wakatsuki T, Takahashi Y, Imamura H, Sato A, Sato M, Ikeda T, Suzuki R, Obara K, Ohira H (2009) Pancreatobiliary drainage using the EUS-FNA technique: EUS-BD and EUS-PD. J Hepatobiliary Pancreat Surg 16:598–604CrossRefPubMedGoogle Scholar
  14. 14.
    Park DH, Koo JE, Oh J, Lee YH, Moon SH, Lee SS, Seo DW, Lee SK, Kim MH (2009) EUS-guided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study. Am J Gastroenterol 104:2168–2174CrossRefGoogle Scholar
  15. 15.
    Itoi T, Itokawa F, Sofuni A, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Moriyasu F (2008) Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography. World J Gastroenterol 14:6078–6082CrossRefPubMedGoogle Scholar
  16. 16.
    Maranki J, Hernandez AJ, Arslan B, Jaffan AA, Angle JF, Shami VM, Kahaleh M (2009) Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography. Endoscopy 41:532–538CrossRefPubMedGoogle Scholar
  17. 17.
    Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM, Yeaton P (2006) Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc 64:52–59CrossRefPubMedGoogle Scholar
  18. 18.
    Weber A, Mittermeyer T, Wagenpfeil S, Schmid RM, Prinz C (2009) Self-expanding metal stents versus polyethylene stents for palliative treatment in patients with advanced pancreatic cancer. Pancreas 38:e7–e12CrossRefPubMedGoogle Scholar
  19. 19.
    Soderlund C, Linder S (2006) Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc 63:986–995CrossRefPubMedGoogle Scholar
  20. 20.
    Bories E, Pesenti C, Caillol F, Lopes C, Giovannini M (2007) Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study. Endoscopy 39:287–291CrossRefPubMedGoogle Scholar
  21. 21.
    van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh H, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ (2010) Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 362:129–137Google Scholar
  22. 22.
    Cotton PB (1982) Duodenoscopic placement of biliary prostheses to relieve malignant obstructive jaundice. Br J Surg 69:501–503CrossRefPubMedGoogle Scholar
  23. 23.
    Flamm CR, Mark DH, Aronson N (2002) Evidence-based assessment of ERCP approaches to managing pancreaticobiliary malignancies. Gastrointest Endosc 56:S218–S225CrossRefPubMedGoogle Scholar
  24. 24.
    Johnson CD (1990) Biliary bypass and palliation for pancreatic cancer. J R Soc Med 83:537PubMedGoogle Scholar
  25. 25.
    Lameris JS, Stoker J, Nijs HG, Zonderland HM, Terpstra OT, van BM, Schutte HE (1991) Malignant biliary obstruction: percutaneous use of self-expandable stents. Radiology 179:703-707Google Scholar
  26. 26.
    McPherson GA, Benjamin IS, Habib NA, Bowley NB, Blumgart LH (1982) Percutaneous transhepatic drainage in obstructive jaundice: advantages and problems. Br J Surg 69:261–264CrossRefPubMedGoogle Scholar
  27. 27.
    Born P, Rosch T, Triptrap A, Frimberger E, Allescher HD, Ott R, Weigert N, Lorenz R, Classen M (1998) Long-term results of percutaneous transhepatic biliary drainage for benign and malignant bile duct strictures. Scand J Gastroenterol 33:544–549CrossRefPubMedGoogle Scholar
  28. 28.
    Wiersema MJ, Sandusky D, Carr R, Wiersema LM, Erdel WC, Frederick PK (1996) Endosonography-guided cholangiopancreatography. Gastrointest Endosc 43:102–106CrossRefPubMedGoogle Scholar
  29. 29.
    Giovannini M, Moutardier V, Pesenti C, Bories E, Lelong B, Delpero JR (2001) Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy 33:898–900CrossRefPubMedGoogle Scholar
  30. 30.
    Shami VM, Kahaleh M (2007) Endoscopic ultrasonography (EUS)-guided access and therapy of pancreatico-biliary disorders: EUS-guided cholangio and pancreatic drainage. Gastrointest Endosc Clin N Am 17:581-viiiGoogle Scholar
  31. 31.
    Yamao K, Bhatia V, Mizuno N, Sawaki A, Ishikawa H, Tajika M, Hoki N, Shimizu Y, Ashida R, Fukami N (2008) EUS-guided choledochoduodenostomy for palliative biliary drainage in patients with malignant biliary obstruction: results of long-term follow-up. Endoscopy 40:340–342CrossRefPubMedGoogle Scholar
  32. 32.
    Kahaleh M, Yoshida C, Kane L, Yeaton P (2004) Interventional EUS cholangiography: a report of five cases. Gastrointest Endosc 60:138–142CrossRefPubMedGoogle Scholar
  33. 33.
    Kahaleh M, Wang P, Shami VM, Tokar J, Yeaton P (2005) EUS-guided transhepatic cholangiography: report of 6 cases. Gastrointest Endosc 61:307–313CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Ali A. Siddiqui
    • 1
    • 2
  • Jayaprakash Sreenarasimhaiah
    • 1
    • 2
  • Luis F. Lara
    • 3
  • William Harford
    • 1
    • 2
  • Calvin Lee
    • 1
  • Mohamad A. Eloubeidi
    • 4
  1. 1.Department of Internal MedicineDallas Veterans Affairs Medical CenterDallasUSA
  2. 2.Department of Medicine, Division of Gastroenterology and HepatologyUniversity of Texas Southwestern Medical SchoolDallasUSA
  3. 3.Departments of Internal MedicineBaylor Medical CenterDallasUSA
  4. 4.Department of Medicine, Division of Gastroenterology and HepatologyThe University of Alabama at BirminghamBirminghamUSA

Personalised recommendations