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EUS-Guided Bilio-Pancreatic Drainage

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ERCP and EUS

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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.

There is less experience with EUS-guided pancreatic drainage and indications for this include mainly benign anastomotic strictures following Whipple surgery. These procedures are arduous, long, and accompanied by relatively high morbidity. Technical success is approximately 75 % with complications including perforation, peripancreatic abscess, and pancreatitis. Similar to EUS-guided biliary drainage, this technique should be confined to expert referral centers experienced in ERCP and EUS.

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Authors and Affiliations

  1. Endoscopic Unit, Department of Gastroenterology, Paoli-Calmettes Institute, 232 Bd St-Marguerite, Cedex 9, Marseille, 13273, France

    Marc Giovannini MD, Erwan Bories MD & Felix Tellez MD

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  1. Marc Giovannini MD
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  2. Erwan Bories MD
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  3. Felix Tellez MD
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Correspondence to Marc Giovannini MD .

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Editors and Affiliations

  1. Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Linda S. Lee

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Video Caption

Video 34.1 EUS-FNA is performed using a 19G needle advanced into the distal CBD from the duodenal bulb in a long position. After bile is aspirated, contrast is injected to perform a cholangiogram demonstrating a diffusely dilated biliary system with no contrast exiting the papilla. A long 0.035 in. guidewire is advanced into the right hepatic duct. Then dilation of the tract is performed using a 4 mm balloon dilator advanced across the choledochoduodenostomy. Finally a 10 mm × 4 cm fully covered metal stent is deployed across the choledochoduodenostomy with the distal end in the duodenal bulb draining bile. Courtesy, Dr. Christopher Thompson, Brigham and Women’s Hospital, Boston, MA

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Giovannini, M., Bories, E., Tellez, F. (2015). EUS-Guided Bilio-Pancreatic Drainage. In: Lee, L. (eds) ERCP and EUS. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2320-5_34

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  • DOI: https://doi.org/10.1007/978-1-4939-2320-5_34

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