Advances in Endoscopic Ultrasound-Guided Biliary Drainage: A Comprehensive Review

Endoscopic retrograde cholangiopancreatography (ERCP) has become the first-line therapy for bile duct drainage. In the hands of experienced endoscopists, conventional ERCP results in a failed cannulation rate of 3% to 5%. This failure can occur more commonly in the setting of altered anatomy or technically difficult cases due to either duodenal or biliary obstruction. In cases of ERCP failure, patients have traditionally been referred for either percutaneous transhepatic biliary drainage (PTBD) or surgery. However, both PTBD and surgery have higher than desirable complication rates. Within the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an attractive alternative to PTBD after failed ERCP. Many groups have reported on the feasibility, efficacy and safety of this technique. This article reviews the indications for ERCP and the currently practiced EUS-BD techniques, including EUS-guided rendezvous, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy.     

Endoscopic ultrasound-guided biliary drainage: Are we there yet?

Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.     

Endoscopic ultrasound-guided biliary drainage: A change in paradigm?

Endoscopic ultrasound-guided biliary drainage(EUS-BD) has been developed as an alternative means of biliary drainage for malignant biliary obstruction(MBO).Compared to percutaneous transhepatic biliary drainage,EUS-BD offers effective internal drainage in a single session in the event of failed endoscopic retrograde cholangiopancreatography and has fewer adverse events(AE). In choosing which technique to use for EUS-BD,a combination of factors appears to be important in decision-making; technical expertise,the risk of AE,and anatomy. With the advent of novel all-in-one EUS-BD specific devices enabling simpler and safer techniques,as well as the growing experience and training of endosonographers,EUS-BD may potentially become a first-line technique in biliary drainage for MBO.     

Endoscopic ultrasonography-guided biliary drainage: Who,when, which,and how?

Both endoscopic ultrasonography(EUS)-guided choledochoduodenostomy( EUS- CDS) and EUS-guided hepaticogastrostomy(EUS-HGS) are relatively well established as alternatives to percutaneous transhepatic biliary drainage(PTBD). Both EUSCDS and EUS-HGS have high technical and clinical success rates(more than 90%) in high-volume centers. Complications for both procedures remain high at 10%-30%. Procedures performed by endoscopists who have done fewer than 20 cases sometimes result in severe or fatal complications. When learning EUSguided biliary drainage(EUS-BD), we recommend a mentor's supervision during at least the first 20 cases. For inoperable malignant lower biliary obstruction, a skillful endoscopist should perform EUS-BD before EUS-guided rendezvous technique(EUS-RV) and PTBD. We should be select EUS-BD for patients having altered anatomy from malignant tumors before balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography, EUS-RV, and PTBD. If both EUS-CDS and EUS-HGS are available, we should select EUS-CDS, according to published data. EUSBD will potentially become a first-line biliary drainage procedure in the near future.     

Does endoscopic ultrasound-guided biliary drainage really have clinical impact?

The well established, gold standard method for treatment of obstructive jaundice involves biliary drainage under endoscopic retrograde cholangiopancreatography(ERCP) performed by pancreatobiliary endoscopists. Recently, interventions using endoscopic ultrasound(EUS) have been developed not only for obtaining cytological and histological diagnosis, but also for biliary drainage as alternative method. EUS-guided biliary drainage(EUSBD) was first reported by Giovannini et al. EUS-BD broadly includes EUS-guided rendezvous technique, EUS-guided choledochoduodenostomy, and EUS-guided hepaticogastrostomy. More recently, EUS-guided antegrade stenting and EUS-guided gallbladder drainage have also been reported. many case reports, series, and retrospective studies on EUS-BD have been reported. However, because prospective studies and comparisons between the different biliary drainage methods have not been reported, the technical success, functional success, adverse events, and stent patency with long-term follow up of EUS-BD are still unclear. Therefore, prospective, randomized controlled studies addressing these issues are needed. Despite this, EUSBD undoubtedly is clinically useful as an alternative biliary drainage method. EUS-BD has the potential to be a first-line biliary drainage method instead of ERCP if results of clinical trials are favorable and the technique is simplified.     

Endoscopic ultrasonography guided drainage:Summary of consortium meeting,May 21,2012,San Diego,California

Endoscopic retrograde cholangiopancreatography(ERCP) is the preferred procedure for biliary and pancreatic drainage.While ERCP is successful in about 95% of cases,a small subset of cases are unsuccessful due to altered anatomy,peri-ampullary pathology,or malignant obstruction.Endoscopic ultrasound-guided drainage is a promising technique for biliary,pancreatic and recently gallbladder decompression,which provides multiple advantages over percutaneous or surgical biliary drainage.Multiple retrospective and some prospective studies have shown endoscopic ultrasoundguided drainage to be safe and effective.Based on the currently reported literature,regardless of the approach,the cumulative success rate is 84%-93% with an overall complication rate of 16%-35%.endoscopic ultrasoundguided drainage seems a viable therapeutic modality for failed conventional drainage when performed by highly skilled advanced endoscopists at tertiary centers with expertise in both echo-endoscopy and therapeutic endoscopy     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound‐guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS‐guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.     

Endoscopic ultrasound-guided drainage of the biliary system:Techniques,indications and future perspectives

Over the last decade, endoscopic ultrasound-guided biliary drainage(EUS-BD)has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde cholangiopancreaticography(ERCP). The available evidence suggests that, in experienced hands, EUS-BD might even replace ERCP as the first-line procedure in specific situations such as malignant distal bile duct obstruction. The aim of this review is to summarize the available data on EUS-BD and propose an evidence-based algorithm clarifies the role of the different EUS-BD techniques in the management of benign and malignant biliary obstructive disease.     

超声内镜引导下胆汁引流治疗ERCP治疗失败的恶性梗阻性黄疸患者疗效初步研究

目的 探讨采用超声内镜引导下胆汁引流术(EUS-BD)和经皮肝胆管引流术(PTBD)再治疗经内镜逆行胰胆管造影术(ERCP)治疗失败的恶性梗阻性黄疸患者的有效性及安全性。方法 2013年1月～2018年12月我院收治的经ERCP治疗失败的恶性梗阻性黄疸患者75例,术前经B超、CT或MRCP等影像学检查证实存在恶性胆管梗阻,其中胰腺癌15例、壶腹部癌12例、胆管癌27例、胆囊癌9例、胃肠道恶性肿瘤侵犯11例和非霍奇金淋巴瘤1例。其中40例接受EUS-BD治疗,35例接受PTBD治疗。结果 在40例EUS-BD治疗患者中,采用超声内镜引导下对接技术完成治疗16例(40.0%),在超声内镜引导下顺行技术完成治疗24例(60.0%),其中37例(92.5%)操作成功,在35例PTBD治疗患者中,28例(80.0%)操作成功,EUS-BD治疗患者操作时间为治疗后,EUS-BD治疗患者血清总胆红素水平为(138.7±50.2)μmol/L,显著低于PTBD治疗患者的(162.4±60.2)μmol/L,而血清白蛋白水平为(34.8±3.7)g/L,显著高于PTBD治疗患者的(32.1±4.6)g/L,P<0.05];EUS-BD治疗患者术后并发症发生率为7.5%(3/40),其中胆道出血2例(5.0%),急性胆管炎1例(2.5%),PTBD治疗患者术后并发症发生率为22.9%(8/35,P<0.05),其中胆道出血3例(8.6%),肝包膜下出血1例(2.9%),胆汁性腹膜炎1例(2.9%),胆漏1例(2.9%),胆道感染2例(5.7%)。结论 在ERCP治疗失败的恶性胆道梗阻患者,可选择EUS-BD或PTBD进行补救治疗,或许可消退黄疸,暂时减轻病情。     

Different options of endosonography-guided biliary drainage after endoscopic retrograde cholangiopancreatography failure

AIM To investigate the success rates of endosonography(EUS)-guided biliary drainage(EUS-BD) techniques after endoscopic retrograde cholangiopancreatography(ERCP) failure for management of biliary obstruction.METHODS From Feb/2010 to Dec/2016, ERCP was performed in 3538 patients, 24 of whom(0.68%) suffered failure to cannulate the biliary tree. All of these patients were initially submitted to EUS-guided rendez-vous(EUS-RV) by means of a transhepatic approach. In case of failure, the next approach was an EUS-guided anterograde stent insertion(EUS-ASI) or an EUS-guided hepaticogastrostomy(EUS-HG). If a transhepatic approach was not possible or a guidewire could not be passed through the papilla, EUS-guided choledochoduodenostomy(EUS-CD) was performed.RESULTS Patients were submitted to EUS-RV(7), EUS-ASI(5), EUS-HG(6), and EUS-CD(6). Success rates did not differ among the various EUS-BD techniques. Overall,technical and clinical success rates were 83.3% and 75%, respectively. Technical success for each technique was, 71.4%, 100%, 83.3%, and 83.3%, respectively(P = 0.81). Complications occurred in 3(12.5%) patients. All of these cases were managed conservatively, but one patient died after rescue percutaneous transhepatic biliary drainage(PTBD).CONCLUSION The choice of a particular EUS-BD technique should be based on patient's anatomy and on whether the guidewire could be passed through the duodenal papilla.     

Endoscopic ultrasound-guided biliary drainage

Endoscopic ultrasound (EUS)-guided biliary drainage has emerged as a minimally invasive alternative to percutaneous and surgical interventions for patients with biliary obstruction who had failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-guided biliary drainage has become feasible due to the development of large channel curvilinear therapeutic echo-endoscopes and the use of real-time ultrasound and fluoroscopy imaging in addition to standard ERCP devices and techniques. EUS-guided biliary drainage is an attractive option because of its minimally invasive, single step procedure which provides internal biliary decompression. Multiple investigators have reported high success and low complication rates. Unfortunately, high quality prospective data are still lacking. We provide detailed review of the use of EUS for biliary drainage from the perspective of practicing endoscopists with specific focus on the technical aspects of the procedure.     

Technical tips for endoscopic ultrasound-guided hepaticogastrostomy

Interventional procedures using endoscopic ultrasound (EUS) have recently been developed. For biliary drainage, EUS-guided trans-luminal drainage has been reported. In this procedure, the transduodenal approach for extrahepatic bile ducts is called EUS-guided choledochoduodenostomy, and the transgastric approach for intrahepatic bile ducts is called EUS-guided hepaticogastrostomy (EUS-HGS). These procedures have several effects, such as internal drainage and avoiding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, and they are indicated for an inaccessible ampulla of Vater due to duodenal obstruction or surgical anatomy. EUS-HGS has particularly wide indications and clinical impact as an alternative biliary drainage method. In this procedure, it is necessary to dilate the fistula, and several devices and approaches have been reported. Stent selection is also important. In previous reports, the overall technical success rate was 82% (221/270), the clinical success rate was 97% (218/225), and the overall adverse event rate for EUS-HGS was 23% (62/270). Adverse events of EUS-biliary drainage are still high compared with ERCP or PTCD. EUS-HGS should continue to be performed by experienced endoscopists who can use various strategies when adverse events occur.     

Recent advances in endoscopic ultrasound‐guided biliary drainage

Endoscopic ultrasound‐guided biliary drainage (EUS‐BD) is increasingly used as an alternative in patients with biliary obstruction who fail standard endoscopic retrograde cholangiopancreatography (ERCP). The two major endoscopic approach routes for EUS‐BD are the transgastric intrahepatic and the transduodenal extrahepatic approaches. Biliary drainage can be achieved by three different methods, transluminal biliary stenting, transpapillary rendezvous technique, and antegrade biliary stenting. Choice of approach route and drainage method depends on individual anatomy, underlying disease, and location of the biliary stricture. Recent meta‐analyses have revealed that cumulative technical success and adverse event rates were 90–94% and 16–23%, respectively. Development of new dedicated devices for EUS‐BD would help refine the technical aspects and minimize the possibility of complications, making it a more promising procedure.     

税制改革背景下会计学专业税法教学存在的问题及对策

税制改革背景下,会计学专业税法教学存在忽视道德素养教育、教学内容重知识轻理论、教学方法单一、实践教学环节弱化等问题。因此,会计学专业税法教学改革应重新定位会计学专业税法教学目标,转变观念,重视税法理论教学,更新教学内容,改进教学方法,加强实践教学环节,让学生真正参与企业实践。     

Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy

AIM: To evaluate the efficacy of endoscopic ultrasound guided biliary drainage(EUS-BD) in patients with surgically altered anatomies.METHODS: We performed a search of the MEDLINE database for studies published between 2001 to July2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms "EUS drainage" and "altered anatomy". All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only fulltext English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth Ⅰ; group 2, Billroth Ⅱ; group 4, Rouxen-Y with gastric bypass; and group 3, all other types. RESULTS: Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion. CONCLUSION: EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrogradecholangiography in centers with expertise in EUS-BD procedures in a research setting.     

Reality named endoscopic ultrasound biliary drainage

Endoscopic ultrasound (EUS) is used for diagnosis and evaluation of many diseases of the gastrointestinal (GI) tract. In the past, it was used to guide a cholangiography, but nowadays it emerges as a powerful therapeutic tool in biliary drainage. The aims of this review are: outline the rationale for endoscopic ultrasound-guided biliary drainage (EGBD); detail the procedural technique; evaluate the clinical outcomes and limitations of the method; and provide recommendations for the practicing clinician. In cases of failed endoscopic retrograde cholangiopancreatography (ERCP), patients are usually referred for either percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Both these procedures have high rates of undesirable complications. EGBD is an attractive alternative to PTBD or surgery when ERCP fails. EGBD can be performed at two locations: transhepatic or extrahepatic, and the stent can be inserted in an antegrade or retrograde fashion. The drainage route can be transluminal, duodenal or transpapillary, which, again, can be antegrade or retrograde [rendezvous (EUS-RV)]. Complications of all techniques combined include pneumoperitoneum, bleeding, bile leak/peritonitis and cholangitis. We recommend EGBD when bile duct access is not possible because of failed cannulation, altered upper GI tract anatomy, gastric outlet obstruction, a distorted ampulla or a periampullary diverticulum, as a minimally invasive alternative to surgery or radiology.     

Endoscopic Ultrasound-Guided Hepaticogastrostomy: Technical Review and Tips to Prevent Adverse Events

Most patients who require biliary drainage can be treated by endoscopic retrograde cholangiopancreatography (ERCP)-guided procedures. However, ERCP can be challenging in patients with complications, such as malignant duodenal obstruction, or a surgically-altered anatomy, such as a Roux-en-Y anastomosis, which prevent advancement of the duodenoscope into the ampulla of Vater. Recently, endoscopic ultrasound (EUS)-guided biliary drainage via transhepatic or transduodenal approaches has emerged as an alternative means of biliary drainage. Typically, EUS-guided gallbladder drainage or choledochoduodenostomy can be performed via both approaches, as can EUS-guided hepaticogastrostomy (HGS). EUS-HGS, because of its transgastric approach, can be performed in patients with malignant duodenal obstruction. Technical tips for EUS-HGS have reached maturity due to device and technical developments. Although the technical success rates of EUS-HGS are high, the rate of adverse events is not low, with stent migration still being reported despite many preventive efforts. In this review, we described technical tips for EUS-HGS related to bile duct puncture, guidewire insertion, fistula dilation, and stent deployment, along with a literature review. Additionally, we provided technical tips to improve the technical success of EUS-HGS.     

Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred modality for drainage of the obstructed biliary tree. In patients with surgically altered anatomy, ERCP using standard techniques may not be feasible. Enteroscope assisted ERCP is usually employed with variable success rate. With advent of endoscopic ultrasound (EUS), biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective. In this narrative review, we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.     

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

AIM: To determine the utility of endoscopic ultrasound-guided biliary drainage (EUS-BD) with a fully covered self-expandable metal stent for managing malignant biliary stricture.METHODS: We collected data from 13 patients who presented with malignant biliary obstruction and underwent EUS-BD with a nitinol fully covered self-expandable metal stent when endoscopic retrograde cholangiopancreatography (ERCP) fails. EUS-guided choledochoduodenostomy (EUS-CD) and EUS-guided hepaticogastrostomy (EUS-HG) was performed in 9 patients and 4 patients, respectively.RESULTS: The technical and functional success rate was 92.3% (12/13) and 91.7% (11/12), respectively. Using an intrahepatic approach (EUS-HG, n = 4), there was mild peritonitis (n = 1) and migration of the metal stent to the stomach (n = 1). With an extrahepatic approach (EUS-CD, n = 10), there was pneumoperitoneum (n = 2), migration (n = 2), and mild peritonitis (n = 1). All patients were managed conservatively with antibiotics. During follow-up (range, 1-12 mo), there was re-intervention (4/13 cases, 30.7%) necessitated by stent migration (n = 2) and stent occlusion (n = 2).CONCLUSION: EUS-BD with a nitinol fully covered self-expandable metal stent may be a feasible and effective treatment option in patients with malignant biliary obstruction when ERCP fails.     

Combination of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography‐guided biliary drainage in malignant hilar biliary obstruction

Adequate biliary drainage (BD), defined as more than 50% of liver volume drained, is an ideal BD method in patients with advanced and unresectable malignant hilar biliary obstruction (MHBO). Endoscopic retrograde cholangiopancreatography (ERCP) with multi‐segmental BD is technically challenging. ERCP with percutaneous biliary drainage (PTBD) or PTBD alone has cumbersome maintenance of PTBD line and external bag. The utility of EUS‐guided BD (EUS‐BD) has risen significantly over last 5 years mostly in the clinical setting of distal bile duct obstruction. Information on EUS‐BD for malignant hilar biliary obstruction (MHBO) is thus far limited to only two small studies. This review suggests a new concept of a combination of ERCP and EUS‐BD (CERES) for BD in MHBO as a primary BD method whereby ERCP with a single self‐expandable metal stent (SEMS) is placed into either the right or the left intrahepatic bile duct (IHD). If SEMS is placed in the right biliary system, EUS‐guided hepaticogastrostomy (EUS‐HGS) can subsequently be carried out. However, if the stent is placed into the left biliary system, EUS‐guided hepaticoduodenostomy (EUS‐HDS) is done. For MHBO with non‐functioning right lobe of the liver, EUS‐HGS is carried out after failed ERCP, or primary HGS can be carried out in the left lobe of liver. For MHBO with non‐functioning left lobe of the liver, EUS‐HDS is carried out after failed transpapillary stenting of the right lobe by ERCP. Based on our experience, CERES is promising as it can fulfil gaps of both PTBD and ERCP by allowing internal drainage that can circumvent the inconvenience associated with PTBD and offer higher technical success rate compared to ERCP with bilateral SEMS placement.