Moving closer to developing an optimal algorithm for EUS-guided biliary drainage

Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic ultrasound (EUS)-guided biliary drainage is an emerging technique that combines the advantages of the endoscopic and percutaneous approaches, without the inconveniences and discomfort of an indwelling external catheter. There has been growing interest and experience in EUS-biliary drainage. Several different EUS-guided techniques have been developed to access the obstructed biliary tree from either the stomach or duodenum, according to the location of the stricture, the anatomy of the patient, and the experience of the endoscopist.

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.

Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage after failed endoscopic retrograde cholangiopancreatography: a meta-analysis

The failure rate of endoscopic retrograde cholangiopancreatography for biliary cannulation is approximately 6%–7% in cases of obstructive jaundice. Percutaneous transhepatic biliary drainage (PTBD) is the procedure of choice in such cases. Endoscopic ultrasound-guided biliary drainage (EGBD) is a novel technique that allows biliary drainage by echoendoscopy and fluoroscopy using a stent from the biliary tree to the gastrointestinal tract. Information in PubMed, Scopus, clinicaltrials.gov and Cochrane review were analyzed to obtain studies comparing EGBD and PTBD. Six studies fulfilled the inclusion criteria. Technical (odds ratio (OR): 0.34; confidence interval (CI) 0.10–1.14; p=0.05) and clinical (OR: 1.48; CI 0.46–4.79; p=0.51) success rates were not statistically significant between the EGBD and PTBD groups. Mild adverse events were nonsignificantly different (OR: 0.36; CI 0.10–1.24; p=0.11) but not the moderate-to-severe adverse events (OR: 0.16; CI 0.08–0.32; p≤0.00001) and total adverse events (OR: 0.34; CI 0.20–0.59; p≤0.0001). EGBD is equally effective but safer than PTBD.

Endoscopic management of acute cholangitis according to the TG13

The Tokyo Guidelines 2013 (TG13) recommend that endoscopic drainage should be the first-choice treatment for biliary decompression in patients with acute cholangitis. Timing of biliary drainage for acute cholangitis should be based on the severity of the disease. For patients with severe acute cholangitis, appropriate organ support and urgent biliary drainage are needed. For patients with moderate acute cholangitis, early biliary drainage is needed. For patients with mild acute cholangitis, biliary drainage is needed when initial treatment such as antimicrobial therapy is ineffective. There are three methods of biliary drainage: endoscopic drainage, percutaneous transhepatic drainage, and surgical drainage. Endoscopic drainage is less invasive than the other two drainage methods. The drainage method (endoscopic nasobiliary drainage and stenting) depends on the endoscopist's preference but endoscopic sphincterotomy should be selected rather than endoscopic papillary balloon dilation from the aspect of procedure-related complications. In the TG13, balloon enteroscopy-assisted and endoscopic ultrasound-guided biliary drainages have been newly added as specific drainage methods. Recent studies have demonstrated their usefulness and safety. These drainage methods will become more widespread in the future.