Clin Endosc.  2023 Mar;56(2):143-154. 10.5946/ce.2022.198.

Endoscopic ultrasound-guided intervention for inaccessible papilla in advanced malignant hilar biliary obstruction

• Pal P
• Lakhtakia S

• KMID: 2540729
• DOI: http://doi.org/10.5946/ce.2022.198

Abstract

Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may be warranted. Transpapillary drainage may not be feasible in patients with surgically altered anatomy, duodenal stenosis, prior duodenal self-expanding metal stent, and after initial transpapillary drainage, but require re-intervention for draining separated liver segments. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous trans-hepatic biliary drainage are the feasible options in this scenario. The major advantages of EUS-BD over percutaneous trans-hepatic biliary drainage include a reduction in patient discomfort and internal drainage away from the tumor, thus reducing the possibility of tissue or tumor ingrowth. With innovations, EUS-BD is helpful not only for bilateral communicating MHBO but also for non-communicating systems with bridging hilar stents or isolated right intra-hepatic duct drainage by hepatico-duodenostomy. EUS-guided multi-stent drainage with specially designed cannulas and guidewires has become a reality. A combined approach with endoscopic retrograde cholangiopancreatography for re-intervention, interventional radiology, and intraductal tumor ablative therapies has been reported. Stent migration and bile leakage can be minimized with proper stent selection and technique, and stent blocks can be managed with EUS-guided interventions in a majority of cases. Future comparative studies are required to establish the role of EUS-guided interventions in MHBO as rescue or primary therapy.

Keyword

Endoscopic ultrasound; Hepatico-duodenostomy; Hepatico-gastrostomy; Inaccessible papilla; Ma-lignant hilar biliary obstruction

Figure

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  Fig. 1. Endoscopic ultrasound (EUS) guided hepatico-gastrostomy (HGS). (A–C) EUS-HGS for isolated left intra-hepatic dilation post-transpapillary self-expanding metal stent (SEMS) placement: (A) Left hepatic duct puncture, (B, C) SEMS placement through EUS-HGS fistula created by EUS guidance. (D–F) EUS-HGS for communicating hilar block: (D) Puncture of left hepatic duct, (E, F) SEMS placement over the guidewire.

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  Fig. 2. Steps of endoscopic ultrasound-guided hepatico-gastrostomy. (A) Puncture site selection, segment 3 duct is preferred over segment 2. (B) Segment 3 duct punctured with 19-G needle and 0.025 stiff guidewire. (C) Deploying the gastric end of the stent within the scope. (D, E) Post-self-expanding metal stent deployment. (F) Final self-expanding metal stent position.

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  Fig. 3. Anchoring plastic stent placement within self-expanding metal stent (SEMS) during endoscopic ultrasound (EUS) guided hepatico-gastrostomy (HGS) (A–C), combined EUS-guided gastrojejunostomy (D), and HGS for malignant obstruction with inaccessible papilla due to duodenal obstruction (E, F). (A) EUS-guided antegrade placement of guidewire across papilla. (B) SEMS placement through HGS fistula. (C) Anchoring plastic stent placement through SEMS. (D) EUS-guided gastrojejunostomy with a hot AXIOS stent. (E) EUS-guided antegrade guidewire passage for inaccessible papilla due to duodenal stenosis. (F) Post SEMS placement.

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  Fig. 4. Approach to biliary drainage for malignant hilar biliary obstruction. SEMS, self-expanding metal stent; ERCP, endoscopic retrograde cholangiopancreatography; PTBD, percutaneous trans-hepatic biliary drainage; EUS-BD, endoscopic ultrasound-guided biliary drainage; HGS, hepatico-gastrostomy; HDS, hepatico-duodenostomy; RV, rendezvous; AS, antegrade stenting; CERES, combined ERCP and EUS-BD.a)Also for isolated right intra-hepatic duct dilation.

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