Interventional EUS as an alternative to endoscopic biliary decompression through the duodenal papilla is feasible and safe

Background and aim: EUS-guided biliary drainage (EUS-BD) has been developed as an alternative drainage procedure in patients with obstructive jaundice when endoscopic biliary drainage (EBD) failed. In addition, EUS-guided gallbladder drainage (EUS-GBD) has been employed as a new procedure which replaces percutaneous transhepatic gallbladder drainage in patients with cholecystitis. We evaluated the feasibility and safety of these procedures.

Patients & methods: From November 2006 to June 2010, EUS-BD was performed on 19 patients with obstructive jaundice, when transpapillary access of the bile duct was impossible. Under EUS guidance, puncture with 19-gauge needle was done from duodenum to extrahepatic bile duct or from stomach to intrahepatic bile duct. After dilation of the puncture route by biliary dilation catheters, a 7Fr stent was mainly placed. EUS-GBD was performed on 2 patients with recurrent cholecystitis after biliary metallic stent deployment which involved cystic duct. The distended gallbladder was punctured with a Zimmon needle knife from the stomach or duodenum under EUS guidance. After dilation of the puncture route, two double-pigtail stents were placed.

Results: EUS-BD was technically successful in all patients (100%); choledochoduodenostomy (EUS-CDS) in 15 of 15, hepaticogastorostomy (EUS-HGS) in 3 of 3 and anterograde drainage across biliary stricture (EUS-AD) in 1 of 1. A self-expandable metallic stent was placed in 3 patients who underwent EUS-HGS and 1 who underwent EUS-AD, while a plastic stent was placed in the other patients. Following successful EUS-BD, biliary decompression was achieved in all patients. The median patency period of the stent were 121 days (12–213). Complications (n=3: 16%) were pneumoperitoneum (n=1; EUS-CDS) and bile leakage (n=2: EUS-HGS). All patients recovered from these morbidities conservatively. EUS-GBD was successful in all 2 patients. No recurrence of cholecystitis was observed (141 and 150 days, respectively). No complications occurred after EUS-GBD.

Conclusion: It is suggested that the interventional EUS of the biliary tract may become an alternative to EBD when it failed. However, dedicated devices are needed for reliable procedures.