Clin Endosc.  2017 Mar;50(2):104-111. 10.5946/ce.2017.036.

Endoscopic Ultrasound-Guided Biliary Access, with Focus on Technique and Practical Tips

• Paik WH
• Park DH

• KMID: 2383526
• DOI: http://doi.org/10.5946/ce.2017.036

Abstract

In 1980, endoscopic ultrasound (EUS) was introduced as a diagnostic tool for evaluation of the pancreas. Since the introduction of curvilinear-array echoendoscopy, EUS has been used for a variety of gastrointestinal interventions, including fine needle aspiration, tumor ablation, and pancreatobiliary access. One of the main therapeutic roles of EUS is biliary drainage as an alternative to endoscopic retrograde biliary drainage (ERBD) or percutaneous transhepatic biliary drainage (PTBD). This article summarizes three different methods of EUS-guided biliary access, with focus on technique and practical tips.

Keyword

Endosonography; Cholestasis; Biliary drainage; Cholangiopancreatography, endoscopic retrograde; Percutaneous transhepatic biliary drainage

MeSH Terms

Biopsy, Fine-Needle
Cholangiopancreatography, Endoscopic Retrograde
Cholestasis
Drainage
Endosonography
Pancreas
Ultrasonography

Figure

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  Fig. 1. Endoscopic ultrasound (EUS)-guided, biliary access algorithm after failed endoscopic retrograde cholangiopancreatography (ERCP).

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  Fig. 2. Endoscopic ultrasound (EUS)-guided rendezvous therapy was performed in an 82-year-old female with malignant distal biliary obstruction due to pancreatic cancer. (A) The dilated common bile duct was punctured at the duodenal bulb with a 19-gauge EUS needle. (B) Contrast was injected under fluoroscopy, and a guidewire was manipulated to pass across the ampulla and looped inside the duodenum. (C) The looped guidewire was grasped with a rat tooth forceps, and pulled through the working channel. (D) A metal stent (white arrows) was inserted in retrograde manner.

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  Fig. 3. Endoscopic ultrasound (EUS)-guided antegrade stenting was performed in a 47-year-old female with malignant distal biliary obstruction due to advanced gastric cancer. The ampulla was not accessible due to previous total gastrectomy with Roux-en-Y anastomosis. (A) The dilated intrahepatic bile duct segment 2 was punctured with a 19-gauge EUS needle. (B) Contrast was injected for cholangiography. (C) A guidewire was placed and coiled inside the common bile duct. (D) A guidewire was manipulated with a 4-F catheter to pass across the papilla. (E) An uncovered metal stent was inserted in antegrade manner (black arrows).

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  Fig. 4. Endoscopic ultrasound (EUS)-guided antegrade stone removal and nasobiliary tube insertion. (A) A dilated intrahepatic bile duct segment 3 was identified on EUS. (B) Contrast was injected into the intrahepatic ducts, and a filling defect (black arrow) was noted at the distal common bile duct. (C) A guidewire was passed across the ampulla, and papillary balloon dilation was performed. (D) Common bile duct stones were removed with a stone-retrieval balloon catheter. (E) A 5-F nasobiliary tube was inserted through the hepaticogastrostomy site in antegrade manner to prevent bile leakage. (F) When contrast was injected via the nasobiliary tube, there were no residual stones. The contrast material drained well through the papilla.

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  Fig. 5. Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was performed in an 85-year-old male with malignant distal biliary obstruction caused by metastatic lymph nodes from lung cancer. (A) The dilated common bile duct was punctured at the duodenal bulb with a 19-gauge EUS needle. (B) Contrast was injected for cholangiography. (C) A guidewire was placed into the left intrahepatic bile duct. (D) A one-step dedicated device for EUS-guided biliary drainage (EUS-BD) was introduced into the common bile duct without additional fistula dilation. (E) A metal stent with anchoring flaps was placed in the duodenal bulb.

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