Endoscopic Ultrasound (EUS)-Guided Biliary Drainage

EUS-guided biliary drainage is an option to treat obstructive jaundice when ERCP drainage fails. These procedures represent alternatives to surgery and percutaneous transhepatic biliary drainage and have been made possible through the continuous development and improvement of EUS scopes and accessories. The development of linear sectorial array EUS scopes in early 1990 brought a new approach to the diagnostic and therapeutic dimensions of echoendoscopy capabilities, opening the possibility to perform puncture over a direct ultrasonographic view. Despite the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty can arise with an ingrown stent tumor, tumor gut compression, periampullary diverticula, and anatomic variation. The EUS-guided technique requires puncture and contrast of the left biliary tree. When performed from the gastric wall, access is obtained through hepatic segment III. Direct common bile duct puncture is achieved from the duodenum. Diathermic dilation of the puncturing tract is performed using a 6F cystotome and a plastic or metallic stent. The technical success of hepaticogastrostomy is near 98%, and complications are present in 20% of cases. The most common complications include pneumoperitoneum, bilioperitoneum, infection, and stent dysfunction. To prevent bile leakage, we used a special partially covered stent (70% covered and 30% uncovered). The overall success rate for choledochoduodenostomy is 92%. The described complications include, in decreasing order of frequency: pneumoperitoneum and focal bile peritonitis, present in 14% of cases. Over the last 15 years, the technique has typically been performed in reference centers, by groups experienced with ERCP. This seems to be a general guideline for safer execution of the procedure.