Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part I (Indications, Outcomes, Comparative Evaluations, Training)

Abstract

Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates.

EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized.

Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Keywords

biliary drainage - endoscopic ultrasound - obstructive jaundice

Introduction

Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al[1] in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%.[2] In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD).[3] While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001.[4] The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction[5] [6] [7] with better success rates.

EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized.

Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India (SGEI) deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Aims

The aim is to discuss and develop consensus statements/recommendations on the key technical aspects in EUS-BD to optimize performance, including the choice of scope, needle, wire, and other accessories used as well as certain EUS-BD-technique specific nuances.

Methods

In 2022, the SGEI board convened the SGEI EUS-BD Consensus Working group comprising of experts in the field of therapeutic endosonography, who are involved in training. Topic-specific task was assigned to the working group members and clinical key questions were generated by them for discussion in the consortium. Searches were performed on Medline and the Cochrane Library till March 2022. The level of evidence for each statement was graded as per the Grading of Recommendation, Assessment, Development and Evaluations system.[8] Recommendations were drafted and the strength was ascertained based on the level of evidence. The members of the expert group met in person to discuss and vote on the recommendations. Voting was done by electronic keypads. Statements with more than 80% total or partial agreement were accepted, while those with major disagreements were discarded or modified after discussion. A second and final round of voting was done to record all statements finally agreed upon. The recommendations developed by this expert group were divided into two parts: (1) general guidance on indications and outcomes, and (2) the technical aspects of “how to do” EUS-BD. This article represents the outcome of the Delphi process resulting in development of guidelines on indications, outcomes, and training.

Centers performing EUS-BD should have a multidisciplinary team comprising of interventional endoscopist, surgeons, and intervention radiologists to support EUS-BD.[9] [10] Pooled adverse event rates have been reported to be 16% for EUS-BD in a meta-analysis with severe adverse events like perforations, bile leaks, and bleeding with a mortality of 0 to 3%.[11] [12] The interventional endoscopist performing the procedure should have vast experience in ERCP and therapeutic EUS as the endoscopist competence determines the outcome of procedure.[13] [14] [15]

To manage severe adverse events and failure of EUS-BD interventional radiological and hepatopancreaticobiliary surgical background is a must.[16] [17] In patients with failed EUS choledochoduodenostomy (EUS-CDS) with punctures crossing the peritoneal cavity, PTBD is required. In patients with maldeployment of hepaticogastrostomy (HGS) stent, with proximal end in the peritoneal cavity after failure of endoscopic correction emergency salvage surgery with repositioning of the stent may be required.[18]

EUS-BD can be performed either by EUS-assisted rendezvous (EUS-RV), or by EUS-guided transluminal stenting including EUS-CDS or EUS-HGS, or by antegrade transpapillary stent (EUS-AGS) placement. The appropriate procedure should be chosen based on the condition of the patient, location of the bile duct obstruction, presence of duodenal obstruction, resectability, and surgical reconstruction.

In patients with hilar biliary obstruction EUS-CDS is not indicated and thus EUS-RV, EUS-AGS, or EUS-HGS should be used. Similarly, in patients with duodenal obstruction or ampullary invasion, EUS-RV is not indicated. However, in patients in whom different approaches are possible comparative studies are lacking and various algorithms have been proposed. Park et al[19] in his study suggested an algorithm for selection of the type of EUS-BD procedure. He proposed that EUS-RV is the first choice for patients with failed ERCP and an accessible ampulla, whereas EUS-HGS or CDS is the first choice for patients with duodenal obstruction depending on the location of the biliary obstruction. Use of the algorithm yielded a success rate of > 90%. In an another study which based procedure selection on the clinical conditions, had a success rate and adverse events similar to those shown by Park et al.[7] Khashab et al proposed a standardized approach for malignant biliary obstruction suggesting EUS-RV should be used first after failed ERCP, and if EUS-RV fails, EUS-CDS/HGS should be done.[20] They showed that the rendezvous and the transluminal techniques have similar efficacy and safety.

Iwashita et al in a prospective pilot study reported the efficacy and safety of EUS-AGS for unresectable malignant biliary obstruction in patients with a surgically altered anatomy and concluded that EUS -AGS is a feasible and safe procedure.[21] Weilert proposed an algorithm, where EUS-AGS using a transgastric intrahepatic bile duct approach was used for patients with failed ERCP.[22] In case of failure of EUS-AGS, EUS-HGS was done and EUS-CDS was performed if HGS failed. Intrahepatic bile duct approach was effective in 80% of cases. In a systematic review of EUS-BD in patients with a surgically altered anatomy it was found that EUS-BD after failed ERCP was as safe and effective as in those with a normal anatomy.[23]

In a study the location of the bile duct obstruction was used to determine whether EUS-CDS or EUS-HGS will be used.[24] For hilar biliary obstruction HGS was used while CDS was used for distal biliary obstruction and they reported technical success of 95.5%, clinical success of 90.5%, and adverse event rates of 9.5%. In another study Gupta et al found that the success rate and adverse event rates were similar between EUS-CDS and EUS-HGS.[25] In a study in patients with combined duodenal and distal biliary obstruction where both EUS-CDS and EUS-HGS can be used, it was shown that EUS-HGS has a significant risk of adverse events and it was proposed that, EUS-CDS may be the first choice in this subset of patients.[26] Li et al[27] compared EUS-HGS and EUS-CDS in a meta-analysis of 12 studies including 2 randomized controlled trials (RCTs) and showed that the cumulative technical success and clinical success for EUS-CDS and EUS-HGS was 95.0% (288/303) and 93.1% (268/288), and 96.6% (309/320) and 91.3% (282/309), respectively. Compared with EUS-HGS, the pooled odds ratio (OR) was 0.74 (95% confidence interval [CI] 0.33–1.65; p = 0.46) for EUS-CDS technical success and 0.94 (95% CI 0.56–1.59; p = 0.83) for clinical success suggesting no significant difference between CDS and HGS. The pooled difference in means of procedure time of EUS-CDS and EUS-HGS was –2.68 (95% CI –5.12 to –0.24; p = 0.03). Compared with EUS-HGS, the pooled OR of early adverse events for EUS-CDS was 0.58 (95% CI: 0.36–0.93; p = 0.02). EUS-CDS and EUS-HGS have equal high technical and clinical success, but EUS-CDS has a slightly short procedure time and less early adverse events compared with EUS-HGS.

Thus, in patients with distal common bile duct obstruction, both procedures are feasible. The choice of the procedure is unclear, but depends on a combination of factors including operator's expertise, stent patency, risk of adverse events, presence of dilated bile duct or biliary radicals, duodenal stenosis, and altered anatomy.

High-quality cross-sectional imaging provides site and location of biliary stricture, delineating the type of hilar obstruction and other relevant bile duct anatomy, and a roadmap for stent placement. It provides the site and location of biliary stricture delineating the type of hilar obstruction and other relevant bile duct anatomy. In patients with hilar obstruction roadmap of the biliary anatomy is a must as inadvertent contrast injection in a nondrainable segment could result in cholangitis. Thus, magnetic resonance cholangiopancreatography prior to intervention is required in patients with hilar obstruction. In patients with distal bile duct obstruction, a contrast-enhanced computed tomography could be performed prior to EUS-BD.

There is a lack of evidence regarding the utility of a roadmap in EUS-BD; however, as in ERCP it has a crucial role to play.[28]

Concerns of EUS-BD in patients with ascites include the risk of failure of formation of mature fistula after procedure and risk of peritonitis due to leakage of bile and intestinal contents. It has been suggested that EUS-BD should not be performed in cases with moderate or tense ascites or ascites present in the puncture route.[29] In addition, the indications for EUS-BD should be carefully assessed even in cases with a small amount of ascites or without ascites in the puncture route. However the concern due to ascites has not been supported in the available scanty literature. In a retrospective feasibility pilot study of EUS-BD for malignant biliary obstruction associated with ascites, 31 patients were included: 20 patients without ascites (group1) and 11 with ascites (group2).[30] Nineteen patients underwent EUS-HGS (6 in group 2), and 12 underwent EUS-CDS (5 in group 2). The procedure was technically successful in all patients. Clinical success was achieved in 95% in group 1 and 64% in group 2 (p = 0.042). Overall rates of procedural-related complications were similar in groups 1 and 2 (20 and 9%, respectively, p = 0.63). Similarly, the rates of major complications (15% vs. 9%, respectively, p = 0.639) were no different in group 1 and group 2. Stent migration occurred in one patient in each group, intra- or postprocedural bleeding occurred in two patients in group 1, which was conservatively managed, and one patient in group 1 was presented with biliary leakage. Stent patency and the number of reinterventions were not significantly different. However, Kamata et al reported a case of HGS stent migration in patient with lower bile duct obstruction with massive ascites.[31] When a therapeutic EUS procedure is still deemed necessary, a preprocedural paracentesis may be helpful before embarking on such a procedure.

Therapeutic EUS procedures are classified “high risk” based on the guideline on antiplatelet or anticoagulation therapy use in endoscopy.[32] Before a therapeutic EUS procedure like EUS-BD, anticoagulant therapy should be temporarily discontinued, while dual-antiplatelet therapy should be converted to aspirin monotherapy wherever possible. However, case series have described successful EUS-BD in patients on anticoagulant and/or antiplatelet therapy without increased risk of bleeding.[33] [34] It has been suggested that the radial expansion forces of the fully covered self-expanding metal stents likely contribute to a reduced risk of periprocedural bleeding by providing a tamponade effect on the intraparietal blood vessels.

Prophylactic broad-spectrum antibiotics may prevent infectious adverse events especially potential peritonitis or progression of peritonitis due to leakage of bile or gastrointestinal (GI) contents following EUS-BD. However, no study has assessed the effectiveness of prophylactic antibiotics in patients undergoing EUS-BD. Since EUS-BD is similar to other biliary interventions like ERCP with contrast injection and manipulation done in an obstructed biliary system, there is a risk of introducing bacteria. The use of antibiotics has been shown to prevent cholangitis, bacteremia, septicemia, and pancreatitis in ERCP, particularly in obstructed biliary system.[35] Thus, prophylactic antibiotics covering biliary flora such as enteric Gram-negative organisms and enterococci should be used prior to EUS-BD.

The main goal of deep sedation for GI endoscopy is to reduce patient discomfort, improve the outcome, and mitigate the patient's memory of the event. Patients undergoing EUS-BD should have adequate airway protection to prevent aspiration Therapeutic EUS may be performed under general anesthesia or in deep sedation without compromising safety.[36]

Endoscopy procedures require gas insufflation to allow the progression of the endoscope and proper examination of the mucosa. It is well established that CO₂ causes less abdominal discomfort because it is absorbed faster than air from the gut and then expired through the lungs. In the American Society for Gastrointestinal Endoscopy technology review it is proposed that CO₂ insufflation in many types of digestive endoscopy procedures is safe and associated with less abdominal pain compared with air insufflation.[37] In a study investigating the role of CO₂ insufflation on abdominal discomfort after EUS it was shown that CO₂ insufflation was associated with lower abdominal discomfort scores at 3 hours after the procedure, compared with air insufflation.[38]

Moreover, it was found that better quality of the EUS images were obtained with CO₂ versus air insufflation.

EUS-BD has been compared with ERCP in three RCTs for primary drainage of malignant distal biliary obstruction.[6] [7] [39] The technical and clinical success rates of EUS-BD and ERCP were similar. One of the RCTs reported fewer adverse events, longer stent patency, and lesser reintervention favoring EUS-BD. Self-expanding metal stents was used in all the studies in both EUS-BD and ERCP groups. In a systematic review and meta-analysis of five studies, 361 patients (190 in the ERCP group and 171 in the EUS group), it was found that the technical and clinical success were comparable.[40] The overall adverse events were similar between the two groups. In the ERCP group, 9.5% of patients developed procedure-related pancreatitis while no patient developed pancreatitis in the EUS group (risk difference = 0.08%, p = 0.02). The rate of reintervention was similar in the two groups. In another meta-analysis of nine studies including 634 patients comparing EUS-BD and ERCP-guided biliary drainage the technical success, clinical success, and adverse events were similar; however, EUS-BD was associated with significantly less reintervention versus ERCP-BD (OR, 0.36, 95% CI, 0.15–0.86).[41]

EUS-BD done in patients with resectable malignant biliary obstruction has not been reported to complicate subsequent surgical resection; however, only two retrospective studies, including a limited number of patients, have assessed the outcomes of preoperative lumen-apposing metal stent (LAMS) placement on surgical outcome.[39] [42]

For patients with failed ERCP, PTBD is a widely available effective technique, however, it may be associated with significant morbidity.[43] EUS-BD has emerged as an acceptable alternative in patients with obstructive jaundice and failed ERCP. Multiple studies, prospective or retrospective, have shown similar technical success (86–100%), with similar or higher clinical success and fewer adverse events, when using EUS-BD.[44] [45] [46] [47] [48] Lee et al[49] performed an RCT comparing EUS-guided and percutaneous drainage for malignant distal biliary obstruction. The RCT included 66 patients, 34 in the EUS-BD group and 32 in the PTBD group and showed similar technical success (94.1% vs. 96.9%) and clinical success (87.5% vs. 87.1%) in the two groups; however, the EUSB-BD group had a significantly lower incidence of adverse events compared with PTBD (8.8% vs. 31.2%, p = 0.022). In a meta- analysis[5] of nine studies including 483 patients, EUS-BD had comparable technical success to PTBD (OR, 1.78; 95% CI, 0.69–4.59), but EUS-BD was associated with higher clinical success (OR, 0.45; 95% CI, 0.23–0.89) and fewer adverse events (OR, 0.23; 95% CI, 0.12–0.47). Hayat et al in a meta-analysis of 10 studies, including 6 RCTs and 4 retrospective studies compared EUS-BD with PTBD.[50] There was no difference between technical and clinical success rates; however, procedural adverse events and total adverse events were significantly higher in the PTBD group. The reintervention rate which was reported in six of these studies was 3.7% in the EUS-BD group versus 13.8% in the PTBD group. This meta-analysis concluded that EUS-BD is equally effective but safer in terms of immediate and total adverse events than PTBD in patients with malignant biliary strictures with failed ERCP.

In patients with malignant hilar obstruction the endoscopic management is difficult and should be performed only in tertiary referral centers with experienced interventional endoscopist. The exact delineation of the biliary anatomy, the type of block, resectability of the lesion, performance status of the patients, and the primary objective of biliary drainage (preoperative or as palliation) needs to be ascertained. Multidisciplinary team involving interventional endoscopist, surgeon, oncologist, and interventional radiologist is required to decide the optimal biliary drainage strategy, placement of plastic or metal stent, and avoiding drainage of atrophic liver segments. In Bismuth type III and IV strictures, PTBD is preferred over ERCP or a combination of PTBD and ERCP is used.[51] Moole et al[52] in a systematic review and meta-analysis in Bismuth type III and IV strictures showed that PTBD achieved adequate biliary drainage more frequently than ERCP (OR 2.53, 95% CI 1.57–4.08). In Bismuth type III and IV strictures drainage of more than 50% of the liver volume is required, which is achieved by stenting of right and left duct or stenting of both right-sided anterior and posterior ducts which is usually achieved by ERCP.[53]

EUS-BD is usually used in surgically unresectable disease or as salvage therapy after metal stent placement in unresectable malignant hilar strictures. Retrospective studies[54] [55] [56] have shown that in malignant hilar biliary obstruction, EUS-BD has a technical success rates of 90%. Kongkam et al[57] in a prospective, multicenter study compared a combination of ERCP and EUS-BD to bilateral PTBD and found that the combined ERCP/EUS-BD approach had a less of recurrent biliary obstruction at 3 and 6 months, with similar adverse events and mortality rates.

Several prospective and retrospective studies[6] [39] [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] have shown that the technical success rates of EUS-CDS range from 88.8 to 100%, and the clinical success rate ranges from 85.5 to 100%. Further, the overall technical success rate is 95.0% (939/988), and the overall clinical success rate is 97.0%.[77] The main indication of EUS-CDS in these studies is failed ERCP; however, few studies which have evaluated the clinical efficacy for primary drainage found high technical and clinical success.[6] [7] [39] EUS-CDS can be performed using self-expandable metal stent (SEMS) or LAMS. Amato et al did a systematic review and meta-analysis of LAMS or SEMS in EUS-CDS which included 31 studies (820 patients).[78] The pooled rates of clinical and technical success were 93.6 and 94.8% for LAMS, and 91.7 and 92.7% for SEMS, respectively. They concluded that the clinical and technical success, postprocedure adverse events, and reintervention rates were similar between LAMS and SEMS.

The rates of technical and clinical success ranged from 65 to 100% and from 73 to 100%, respectively, in various series of EUS- HGS.[6] [13] [44] [54] [60] [79] [80] [81] [82] [83] [84] Mao et al[85] in a recent systematic review and meta-analysis compared EUS-CDS and EUS-HGS in malignant biliary obstruction. This systematic review included 13 studies and 759 patients (EUS-CDS: 359, EUS-HGS: 400), and reported a comparable technical success (EUS-CDS: 94.2%, EUS-HGS: 94.8%) and clinical success (EUS-CDS: 90%, EUS-HGS: 89.5%). It was concluded that EUS-CDS and EUS-HGS have comparable technical and clinical success rates, adverse events, and overall survival. However, EUS-CDS has less reintervention and stent obstruction. In another meta-analysis of 12 studies with 623 patients (EUS-CDS: 303 and EUS-HGS: 320), the cumulative technical success and clinical success for EUS-CDS and EUS-HGS was 95.0 and 93.1% and 96.6 and 91.3%, respectively.[27] The cumulative early adverse events for EUS-CDS and EUS-HGS was 12.2 and 17.5%, respectively.

EUS-HGS in malignant hilar biliary obstruction is indicated in patients who have failed ERCP, surgically altered anatomy, or in patients with failed reintervention of occluded transpapillary stents. EUS-HGS is mainly used for inoperable patients. In patients with hilar block the techniques used for drainage include EUS-HGS, EUS-guided hepaticoduodenostomy (EUS-HDS), bridging method, or a combination of ERCP and EUS (CERES).[86] Few case series have reported use of EUS-HGS in hilar block. In a case series by Ogura et al EUS-BD as a rescue was done after failed ERCP in 10 patients, with EUS-HGS in 8 patients and EUS-HDS in 2 patients.[87] Technical success was 100% while clinical success was achieved in 90%. In another series by Moryoussef et al,[55] 18 patients with hilar biliary obstruction and failed ERCP underwent EUS-HGS, technical success was achieved in 94% with clinical success being 72% at 1 week and 68% at 30 days. The reintervention rate was 16.4%. The low rate of clinical success was possibly related to the type of block which was, type I/II in 47%, type III in 47%, and type IV in 6%. In another series by Minaga et al of 30 patients, 16.6% had type II block, 43.3% had type III block, and 40% had type IV block.[54] Technical success was 96.6% and clinical success in those with technical success was 75.4%. In this series, 28 patients underwent EUS-HGS and 2 patients underwent EUS-HDS. Median stent patency duration was only 62.5 days. On multivariate analysis, Bismuth type IV block was the only factor associated with clinical ineffectiveness of EUS-BD.

EUS-guided antegrade stenting for patients with 20 or more patients has been reported only in a few studies. In the study by Iwashita et al[88] of 20 patients, the technical and clinical success was 95%. Rate of adverse events was 20%, including mild pancreatitis in three and mild fever in one patient, which were successfully managed conservatively. In another retrospective study by Vanella et al[89] of 45 patients the technical success was 86.5% and clinical success was 75.1%. The success rate of EUS-AGS is inferior to that of EUS-HGS or EUS-CDS owing to the difficulty of guidewire passage and stent delivery system insertion across the strictures. In a recent large retrospective study on EUS-AGS in 54 patients,[90] indication was palliative in 34 (62.9%) patients and preoperative in 20 (37%) patients. Technical success of EUS-AG was 88.7%. Clinical success was seen in 95.7% patients. No procedure-related severe adverse events were seen.

A large number of single-center retrospective studies[91] [92] [93] [94] [95] [96] including more than 30 patients has shown technical success ranging from 65 to 98% with adverse events in 8 to 23% with EUS-RV. In a prospective observational study involving 12 centers and 20 patients EUS-RV was done in failed biliary cannulation in benign and resectable malignant biliary disorders with an overall technical success of 85% and adverse events of 15% (pancreatitis and biliary peritonitis).[97] Klair et al[98] did a systematic review and a proportion meta-analysis of EUS-RV after failed biliary cannulation involving 12 studies with 342 patients. The pooled rate of technical success was 86.1% while the pooled rate of clinical success was 80.8%. The pooled rate of overall adverse events was 14% (95% CI: 10.5–18.4). Due to the risk of adverse events EUS-RV should be done in centers with expertise in interventional EUS.

Training Requirements

To achieve proficiency in therapeutic EUS, competence in diagnostic EUS is mandatory.[15] As therapeutic EUS require handling of wire and stent placement, hence competence in ERCP is required whereas competence in therapeutic luminal endoscopy is advantageous. Furthermore, it is suggested that EUS-guided fine needle aspiration/FNB can be commenced early in training to acquire safe handling and appropriate positioning of the scope. After acquiring competence in diagnostic EUS, therapeutic EUS should be started with less drainage of pancreatic fluid collection and then to advance EUS interventions like EUS-BD, EUS-guided gallbladder drainage, or EUS-guided gastroenterostomy.

In a study by Tyberg et al[99] about the learning curve in EUS-BD, consecutive 72 patients undergoing EUS-BD by an operator were included over 6 years' period. It was found the operator is able to achieve reduction in procedure time over successive cases, with efficiency reached at 32 cases. For mastery approximately 100 cases are required.

To be efficient in EUS-BD the training needs to be initiated in a stepwise manner. Simulation-based training refers to a training tool whereby repetitive instructions are provided in a model without anxiety and risks involved in a live patient.[15] This may include mechanical simulators, animal models, and computer-based simulators. Following simulation-based training, hands-on training may be imparted.

Dhir et al[100] did a prospective observational feasibility study of a novel ex vivo model for hands-on teaching of and training in EUS-guided biliary drainage. A prototype of dilated biliary system was created using computer-aided design and three-dimensional (3D) printing for manipulation of guidewire and EUS-CDS and EUS-AGS. They concluded that the 3D printing bile duct prototype appears suitable for teaching and training in the various steps of EUS-BD.

Conflict of Interest

None declared.

• References

• 1 McCune WS, Shorb PE, Moscovitz H. Endoscopic cannulation of the ampulla of Vater: a preliminary report. Ann Surg 1968; 167 (05) 752-756
• 2 Mukai S, Itoi T, Baron TH. et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. J Hepatobiliary Pancreat Sci 2017; 24 (10) 537-549
• 3 Holt BA, Hawes R, Hasan M. et al. Biliary drainage: role of EUS guidance. Gastrointest Endosc 2016; 83 (01) 160-165
• 4 Giovannini M, Moutardier V, Pesenti C, Bories E, Lelong B, Delpero JR. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy 2001; 33 (10) 898-900
• 5 Sharaiha RZ, Khan MA, Kamal F. et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis. Gastrointest Endosc 2017; 85 (05) 904-914
• 6 Paik WH, Lee TH, Park DH. et al. EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: a multicenter randomized clinical trial. Am J Gastroenterol 2018; 113 (07) 987-997
• 7 Park JK, Woo YS, Noh DH. et al. Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study. Gastrointest Endosc 2018; 88 (02) 277-282
• 8 Guyatt G, Oxman AD, Akl EA. et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011; 64 (04) 383-394
• 9 Kahaleh M, Artifon EL, Perez-Miranda M. et al. Endoscopic ultrasonography guided biliary drainage: summary of consortium meeting, May 7th, 2011, Chicago. World J Gastroenterol 2013; 19 (09) 1372-1379
• 10 Teoh AYB, Dhir V, Kida M. et al. Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 2018; 67 (07) 1209-1228
• 11 Han SY, Kim SO, So H, Shin E, Kim DU, Park DH. EUS-guided biliary drainage versus ERCP for first-line palliation of malignant distal biliary obstruction: a systematic review and meta-analysis. Sci Rep 2019; 9 (01) 16551
• 12 Kanno Y, Koshita S, Ogawa T. et al. EUS-guided biliary drainage for unresectable malignant biliary obstruction: 10-year experience of 99 cases at a single center. J Gastrointest Cancer 2019; 50 (03) 469-477
• 13 Poincloux L, Rouquette O, Buc E. et al. Endoscopic ultrasound-guided biliary drainage after failed ERCP: cumulative experience of 101 procedures at a single center. Endoscopy 2015; 47 (09) 794-801
• 14 Tyberg A, Mishra A, Cheung M. et al. Learning curve for EUS-guided biliary drainage: what have we learned?. Endosc Ultrasound 2020; 9 (06) 392-396
• 15 Johnson G, Webster G, Boškoski I. et al. Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2021; 53 (10) 1071-1087
• 16 Minaga K, Kitano M, Yamashita Y, Nakatani Y, Kudo M. Stent migration into the abdominal cavity after EUS-guided hepaticogastrostomy. Gastrointest Endosc 2017; 85 (01) 263-264
• 17 Okuno N, Hara K, Mizuno N, Hijioka S, Imaoka H, Yamao K. Stent migration into the peritoneal cavity following endoscopic ultrasound-guided hepaticogastrostomy. Endoscopy 2015; 47 (Suppl 1 UCTN): E311
• 18 Sodarat P, Luangsukrerk T, Kongkam P, Seabmuangsai O, Wachiramatharuch C. Surgical hepaticogastrostomy as a method for resolving stent migration in endoscopic ultrasound-guided hepaticogastrostomy. Endoscopy 2021; 53 (09) E350-E351
• 19 Park DH, Jeong SU, Lee BU. et al. Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video). Gastrointest Endosc 2013; 78 (01) 91-101
• 20 Khashab MA, Valeshabad AK, Modayil R. et al. EUS-guided biliary drainage by using a standardized approach for malignant biliary obstruction: rendezvous versus direct transluminal techniques (with videos). Gastrointest Endosc 2013; 78 (05) 734-741
• 21 Iwashita T, Yasuda I, Doi S. et al. Endoscopic ultrasound-guided antegrade treatments for biliary disorders in patients with surgically altered anatomy. Dig Dis Sci 2013; 58 (08) 2417-2422
• 22 Weilert F. Prospective evaluation of simplified algorithm for EUS-guided intra-hepatic biliary access and anterograde interventions for failed ERCP. Surg Endosc 2014; 28 (11) 3193-3199
• 23 Siripun A, Sripongpun P, Ovartlarnporn B. Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy. World J Gastrointest Endosc 2015; 7 (03) 283-289
• 24 Prachayakul V, Aswakul P. A novel technique for endoscopic ultrasound-guided biliary drainage. World J Gastroenterol 2013; 19 (29) 4758-4763
• 25 Gupta K, Perez-Miranda M, Kahaleh M. et al; InEBD STUDY GROUP. Endoscopic ultrasound-assisted bile duct access and drainage: multicenter, long-term analysis of approach, outcomes, and complications of a technique in evolution. J Clin Gastroenterol 2014; 48 (01) 80-87
• 26 Dhir V, Artifon EL, Gupta K. et al. Multicenter study on endoscopic ultrasound-guided expandable biliary metal stent placement: choice of access route, direction of stent insertion, and drainage route. Dig Endosc 2014; 26 (03) 430-435
• 27 Li J, Tang J, Liu F, Fang J. Comparison of choledochoduodenostomy and hepaticogastrostomy for EUS-guided biliary drainage: a meta-analysis. Front Surg 2022; 9: 811005
• 28 Freeman ML, Overby C. Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents. Gastrointest Endosc 2003; 58 (01) 41-49
• 29 Isayama H, Nakai Y, Itoi T. et al. Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018. J Hepatobiliary Pancreat Sci 2019; 26 (07) 249-269
• 30 Alvarez-Sánchez MV, Luna OB, Oria I. et al. Feasibility and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) for malignant biliary obstruction associated with ascites: results of a pilot study. J Gastrointest Surg 2018; 22 (07) 1213-1220
• 31 Kamata K, Takenaka M, Minaga K. et al. Stent migration during EUS-guided hepaticogastrostomy in a patient with massive ascites: troubleshooting using additional EUS-guided antegrade stenting. Arab J Gastroenterol 2017; 18 (02) 120-121
• 32 Veitch AM, Radaelli F, Alikhan R. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53 (09) 947-969
• 33 Anderloni A, Attili F, Sferrazza A. et al. EUS-guided gallbladder drainage using a lumen-apposing self-expandable metal stent in patients with coagulopathy or anticoagulation therapy: a case series. Endosc Int Open 2017; 5 (11) E1100-E1103
• 34 Ogura T, Nishioka N, Ueno S. et al. Antiplatelet and/or anticoagulant treatment does not increase hemorrhagic adverse events during EUS-guided biliary drainage. Gastrointest Endosc 2020; 92 (03) 659-666
• 35 Brand M, Bizos D, O'Farrell Jr P. Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography. Cochrane Database Syst Rev 2010; (10) CD007345
• 36 Early DS, Lightdale JR, Vargo II JJ. et al; ASGE Standards of Practice Committee. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2018; 87 (02) 327-337
• 37 Lo SK, Fujii-Lau LL, Enestvedt BK. et al; ASGE Technology Committee. The use of carbon dioxide in gastrointestinal endoscopy. Gastrointest Endosc 2016; 83 (05) 857-865 (This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited)
• 38 Serrani M, Lisotti A, Spada A, Sferrazza S, Calvanese C, Fusaroli P. CO ₂ vs. air insufflation in endoscopic ultrasonography: a prospective study. Endosc Int Open 2019; 7 (03) E317-E321
• 39 Bang JY, Navaneethan U, Hasan M, Hawes R, Varadarajulu S. Stent placement by EUS or ERCP for primary biliary decompression in pancreatic cancer: a randomized trial (with videos). Gastrointest Endosc 2018; 88 (01) 9-17
• 40 Kakked G, Salameh H, Cheesman AR, Kumta NA, Nagula S, DiMaio CJ. Primary EUS-guided biliary drainage versus ERCP drainage for the management of malignant biliary obstruction: a systematic review and meta-analysis. Endosc Ultrasound 2020; 9 (05) 298-307
• 41 Lyu Y, Li T, Cheng Y, Wang B, Cao Y, Wang Y. Endoscopic ultrasound-guided vs ERCP-guided biliary drainage for malignant biliary obstruction: a up-to-date meta-analysis and systematic review. Dig Liver Dis 2021; 53 (10) 1247-1253
• 42 Gaujoux S, Jacques J, Bourdariat R. et al. Pancreaticoduodenectomy following endoscopic ultrasound-guided choledochoduodenostomy with electrocautery-enhanced lumen-apposing stents an ACHBT - SFED study. HPB (Oxford) 2021; 23 (01) 154-160
• 43 Nennstiel S, Weber A, Frick G. et al. Drainage-related complications in percutaneous transhepatic biliary drainage: an analysis over 10 years. J Clin Gastroenterol 2015; 49 (09) 764-770
• 44 Sportes A, Camus M, Greget M. et al. Endoscopic ultrasound-guided hepaticogastrostomy versus percutaneous transhepatic drainage for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography: a retrospective expertise-based study from two centers. Therap Adv Gastroenterol 2017; 10 (06) 483-493
• 45 Artifon EL, Aparicio D, Paione JB. et al. Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage. J Clin Gastroenterol 2012; 46 (09) 768-774
• 46 Bapaye A, Dubale N, Aher A. Comparison of endosonography-guided vs. percutaneous biliary stenting when papilla is inaccessible for ERCP. United European Gastroenterol J 2013; 1 (04) 285-293
• 47 Khashab MA, Valeshabad AK, Afghani E. et al. A comparative evaluation of EUS-guided biliary drainage and percutaneous drainage in patients with distal malignant biliary obstruction and failed ERCP. Dig Dis Sci 2015; 60 (02) 557-565
• 48 Sharaiha RZ, Kumta NA, Desai AP. et al. Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: predictors of successful outcome in patients who fail endoscopic retrograde cholangiopancreatography. Surg Endosc 2016; 30 (12) 5500-5505
• 49 Lee TH, Choi JH, Park H. et al. Similar efficacies of endoscopic ul- trasound-guided transmural and percutaneous drainage for malignant distal biliary obstruction. Clin Gastroenterol Hepatol 2016; 14 (07) 1011-1019.e3
• 50 Hayat U, Bakker C, Dirweesh A. et al. EUS-guided versus percutaneous transhepatic cholangiography biliary drainage for obstructed distal malignant biliary strictures in patients who have failed endoscopic retrograde cholangiopancreatography: a systematic review and meta-analysis. Endosc Ultrasound 2022; 11 (01) 4-16
• 51 Dumonceau JM, Tringali A, Papanikolaou IS. et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017. Endoscopy 2018; 50 (09) 910-930
• 52 Moole H, Dharmapuri S, Duvvuri A. et al. Endoscopic versus percutaneous biliary drainage in palliation of advanced malignant hilar obstruction: a meta-analysis and systematic review. Can J Gastroenterol Hepatol 2016; 2016: 4726078
• 53 Coelen RJS, Roos E, Wiggers JK. et al. Endoscopic versus percutaneous biliary drainage in patients with resectable perihilar cholangiocarcinoma: a multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol 2018; 3 (10) 681-690
• 54 Minaga K, Takenaka M, Kitano M. et al. Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention. Surg Endosc 2017; 31 (11) 4764-4772
• 55 Moryoussef F, Sportes A, Leblanc S, Bachet JB, Chaussade S, Prat F. Is EUS-guided drainage a suitable alternative technique in case of proximal biliary obstruction?. Therap Adv Gastroenterol 2017; 10 (07) 537-544
• 56 Vanella G, Bronswijk M, Maleux G, van Malenstein H, Laleman W, Van der Merwe S. EUS-guided intrahepatic biliary drainage: a large retrospective series and subgroup comparison between percutaneous drainage in hilar stenoses or postsurgical anatomy. Endosc Int Open 2020; 8 (12) E1782-E1794
• 57 Kongkam P, Orprayoon T, Boonmee C. et al. ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: a multicenter observational open-label study. Endoscopy 2021; 53 (01) 55-62
• 58 Kunda R, Pérez-Miranda M, Will U. et al. EUS-guided choledochoduodenostomy for malignant distal biliary obstruction using a lumen-apposing fully covered metal stent after failed ERCP. Surg Endosc 2016; 30 (11) 5002-5008
• 59 Kawakubo K, Kawakami H, Kuwatani M. et al. Endoscopic ultrasound-guided choledochoduodenostomy vs. transpapillary stenting for distal biliary obstruction. Endoscopy 2016; 48 (02) 164-169
• 60 Khashab MA, Messallam AA, Penas I. et al. International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs. choledochoduodenostomy approaches. Endosc Int Open 2016; 4 (02) E175-E181
• 61 Cho DH, Lee SS, Oh D. et al. Long-term outcomes of a newly developed hybrid metal stent for EUS-guided biliary drainage (with videos). Gastrointest Endosc 2017; 85 (05) 1067-1075
• 62 Lu L, Tang X, Jin H, Yang J, Zhang X. Endoscopic ultrasound- guided biliary drainage using self-expandable metal stent for malignant biliary obstruction. Gastroenterol Res Pract 2017; 2017: 6284094
• 63 Rai P, Lokesh CR, Goel A, Aggarwal R. Endoscopic ultrasound-guided choledochoduodenostomy using partially-covered self-expandable metal stent in patients with malignant distal biliary obstruction and unsuccessful ERCP. Endosc Int Open 2018; 6 (01) E67-E72
• 64 Tsuchiya T, Teoh AYB, Itoi T. et al. Long-term outcomes of EUS-guided choledochoduodenostomy using a lumen-apposing metal stent for malignant distal biliary obstruction: a prospective multicenter study. Gastrointest Endosc 2018; 87 (04) 1138-1146
• 65 Minaga K, Ogura T, Shiomi H. et al. Comparison of the efficacy and safety of endoscopic ultrasound-guided choledochoduodenostomy and hepaticogastrostomy for malignant distal biliary obstruction: multicenter, randomized, clinical trial. Dig Endosc 2019; 31 (05) 575-582
• 66 El Chafic AH, Shah JN, Hamerski C. et al. EUS-guided choledochoduodenostomy for distal malignant biliary obstruction using electrocautery-enhanced lumen-apposing metal stents: first US, multicenter experience. Dig Dis Sci 2019; 64 (11) 3321-3327
• 67 Itonaga M, Kitano M, Hatamaru K. et al. Endoscopic ultrasound-guided choledochoduodenostomy using a thin stent delivery system in patients with unresectable malignant distal biliary obstruction: a prospective multicenter study. Dig Endosc 2019; 31 (03) 291-298
• 68 Nakai Y, Isayama H, Kawakami H. et al. Prospective multicenter study of primary EUS-guided choledochoduodenostomy using a covered metal stent. Endosc Ultrasound 2019; 8 (02) 111-117
• 69 Anderloni A, Fugazza A, Troncone E. et al. Single-stage EUS-guided choledochoduodenostomy using a lumen-apposing metal stent for malignant distal biliary obstruction. Gastrointest Endosc 2019; 89 (01) 69-76
• 70 Jacques J, Privat J, Pinard F. et al. Endoscopic ultrasound-guided choledochoduodenostomy with electrocautery-enhanced lumen-apposing stents: a retrospective analysis. Endoscopy 2019; 51 (06) 540-547
• 71 Teoh AYB, Kongkam P, Bapaye A. et al. The use of a novel lumen- apposing metallic stent for drainage of the bile duct and gallbladder: long term outcomes of a prospective international trial. Dig Endosc 2021; 33 (07) 1139-1145
• 72 Chin JY, Seleq S, Weilert F. Safety and outcomes of endoscopic ultrasound-guided drainage for malignant biliary obstruction using cautery-enabled lumen-apposing metal stent. Endosc Int Open 2020; 8 (11) E1633-E1638
• 73 de Benito Sanz M, Nájera-Muñoz R, de la Serna-Higuera C. et al. Lumen apposing metal stents versus tubular self-expandable metal stents for endoscopic ultrasound-guided choledochoduodenostomy in malignant biliary obstruction. Surg Endosc 2021; 35 (12) 6754-6762
• 74 Matsumoto S, Hara K, Mizuno N. et al. Risk factor analysis for adverse events and stent dysfunction of endoscopic ultrasound-guided choledochoduodenostomy. Dig Endosc 2020; 32 (06) 957-966
• 75 Kuraoka N, Hara K, Okuno N. et al. Outcomes of EUS-guided choledochoduodenostomy as primary drainage for distal biliary obstruction with covered self-expandable metallic stents. Endosc Int Open 2020; 8 (07) E861-E868
• 76 Jacques J, Privat J, Pinard F. et al. EUS-guided choledochoduodenostomy by use of electrocautery-enhanced lumen-apposing metal stents: a French multicenter study after implementation of the technique (with video). Gastrointest Endosc 2020; 92 (01) 134-141
• 77 Ogura T, Itoi T. Technical tips and recent development of endoscopic ultrasound-guided choledochoduodenostomy. DEN Open 2021; 1 (01) e8
• 78 Amato A, Sinagra E, Celsa C. et al. Efficacy of lumen-apposing metal stents or self-expandable metal stents for endoscopic ultrasound-guided choledochoduodenostomy: a systematic review and meta-analysis. Endoscopy 2021; 53 (10) 1037-1047
• 79 Park DH, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc 2011; 74 (06) 1276-1284
• 80 Vila JJ, Pérez-Miranda M, Vazquez-Sequeiros E. et al. Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey. Gastrointest Endosc 2012; 76 (06) 1133-1141
• 81 Nakai Y, Isayama H, Yamamoto N. et al. Safety and effectiveness of a long, partially covered metal stent for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction. Endoscopy 2016; 48 (12) 1125-1128
• 82 Oh D, Park DH, Song TJ. et al. Optimal biliary access point and learning curve for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting. Therap Adv Gastroenterol 2017; 10 (01) 42-53
• 83 Honjo M, Itoi T, Tsuchiya T. et al. Safety and efficacy of ultra-tapered mechanical dilator for EUS-guided hepaticogastrostomy and pancreatic duct drainage compared with electrocautery dilator (with video). Endosc Ultrasound 2018; 7 (06) 376-382
• 84 Nakai Y, Sato T, Hakuta R. et al. Long-term outcomes of a long, partially covered metal stent for EUS-guided hepaticogastrostomy in patients with malignant biliary obstruction (with video). Gastrointest Endosc 2020; 92: 623-631.e1
• 85 Mao K, Hu B, Sun F, Wan K. Choledochoduodenostomy versus hepaticogastrostomy in endoscopic ultrasound-guided drainage for malignant biliary obstruction: a meta-analysis and systematic review. Surg Laparosc Endosc Percutan Tech 2021; 32 (01) 124-132
• 86 Kongkam P, Tasneem AA, Rerknimitr R. Combination of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography-guided biliary drainage in malignant hilar biliary obstruction. Dig Endosc 2019; 31 (Suppl. 01) 50-54
• 87 Ogura T, Onda S, Takagi W. et al. Clinical utility of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention procedure for high-grade hilar stricture. J Gastroenterol Hepatol 2017; 32 (01) 163-168
• 88 Iwashita T, Yasuda I, Mukai T. et al. Endoscopic ultrasound-guided antegrade biliary stenting for unresectable malignant biliary obstruction in patients with surgically altered anatomy: single-center prospective pilot study. Dig Endosc 2017; 29 (03) 362-368
• 89 Vanella G, Bronswijk M, Maleux G, van Malenstein H, Laleman W, Van der Merwe S. EUS-guided intrahepatic biliary drainage: a large retrospective series and subgroup comparison between percutaneous drainage in hilar stenoses or postsurgical anatomy. Endosc Int Open 2020; 8 (12) E1782-E1794
• 90 Sundaram S, Mane K, Patil P. et al. Endoscopic ultrasound-guided antegrade stent placement in patients with failed ERCP as a modality of preoperative and palliative biliary drainage. Dig Dis Sci 2022
• 91 Maranki J, Hernandez AJ, Arslan B. et al. Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography. Endoscopy 2009; 41 (06) 532-538
• 92 Iwashita T, Lee JG, Shinoura S. et al. Endoscopic ultrasound-guided rendezvous for biliary access after failed cannulation. Endoscopy 2012; 44 (01) 60-65
• 93 Shah JN, Marson F, Weilert F. et al. Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla. Gastrointest Endosc 2012; 75 (01) 56-64
• 94 Dhir V, Bhandari S, Bapat M, Maydeo A. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos). Gastrointest Endosc 2012; 75 (02) 354-359
• 95 Dhir V, Bhandari S, Bapat M, Joshi N, Vivekanandarajah S, Maydeo A. Comparison of transhepatic and extrahepatic routes for EUS-guided rendezvous procedure for distal CBD obstruction. United European Gastroenterol J 2013; 1 (02) 103-108
• 96 Nakai Y, Isayama H, Matsubara S. et al. A novel “hitch-and-ride” deep biliary cannulation method during rendezvous endoscopic ultrasound-guided ERCP technique. Endoscopy 2017; 49 (10) 983-988
• 97 Shiomi H, Yamao K, Hoki N. et al. Endoscopic ultrasound-guided rendezvous technique for failed biliary cannulation in benign and resectable malignant biliary disorders. Dig Dis Sci 2018; 63 (03) 787-796
• 98 Klair JS, Zafar Y, Ashat M. et al. Effectiveness and safety of EUS rendezvous after failed biliary cannulation with ERCP: a systematic review and proportion meta-analysis. J Clin Gastroenterol 2023; 57 (02) 211-217
• 99 Tyberg A, Mishra A, Cheung M. et al. Learning curve for EUS-guided biliary drainage: what have we learned?. Endosc Ultrasound 2020; 9 (06) 392-396
• 100 Dhir V, Itoi T, Fockens P. et al. Novel ex vivo model for hands-on teaching of and training in EUS-guided biliary drainage: creation of “Mumbai EUS” stereolithography/3D printing bile duct prototype (with videos). Gastrointest Endosc 2015; 81 (02) 440-446

Publication History

Article published online:
01 March 2023