EUS-guided biliary drainage: a case series

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is the most appropriate technique to treat common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Biliary and/or pancreatic duct cannulation and visualization are successful with ERCP in a high percentage of cases managed by experienced hands [1] [2] [3]. Common causes of failure include complex peripapillary diverticula, prior surgery procedures such as gastrectomy with Billroth II anastomosis, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones [4].

Percutaneous transhepatic cholangiography (PTC) [5] and surgery are the alternative approaches to access and drain obstructed ducts. The development of the large channel linear array echoendoscope allows for therapeutic procedures such as fine needle aspiration (FNA) and biopsy [6], celiac plexus neurolysis [7], pancreatic pseudocyst [8], and perirectal and retroperitoneal abscess drainage [9].

Since 1996 when Wiersema et al. first described endoscopic ultrasound (EUS)-guided bile duct puncture [10], several case reports have been published on EUS-guided biliary and pancreatic duct puncture and drainage [11] [12] [13] [14] [15] [16] [17] [18] [19]. These case reports illustrate different techniques to approach bile and pancreatic ducts: transgastric or transduodenal puncture, rendezvous after positioning a guide wire through the papilla, or creating a new papilla by fistula formation. In all of these reports, interventional EUS proved feasible and safe with a low rate of complications, but only few series have been published.

Kahaleh et al. have recently described a series of 23 patients treated with interventional endoscopic ultrasound cholangiography (IEUC). Biliary decompression was accomplished in more than 90 % of the cases that had previously received ERCP without success; in one of these cases, bile leakage occurred using the extrahepatic approach [20].

We describe a series of consecutive patients in whom ERCP failed for different reasons ([Table 1]), and IEUC was applied instead of the traditional percutaneous approach.

• 1 Ponchon T, Pilleul F. Diagnostic ERCP.  Endoscopy. 2002;  34 29-42
• 2 Cortas G A, Mehta S N, Abraham N S, Barkun A N. Selective cannulation of the common bile duct: a prospective randomized trial comparing standard catheters with sphincterotomes.  Gastrointest Endosc. 1999;  50 775-779
• 3 Schofl R. Diagnostic endoscopic retrograde cholangiopancreatography.  Endoscopy. 2001;  33 147-157
• 4 Martin D F. Combined percutaneous and endoscopic procedures for bile duct obstruction.  Gut. 1994;  35 1011-1012
• 5 Ferrucci Jr J T, Mueller P R, Harbin W P. Percutaneous transhepatic biliary drainage: technique, results, and application.  Radiology. 1980;  135 1-13
• 6 Wiersema M J, Vilmann P, Giovannini M. et al . Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment.  Gastroenterology. 1997;  112 1087-1095
• 7 Abedi M, Zfass A M. Endoscopic ultrasound-guided (neurolytic) celiac plexus block.  J Clin Gastroenterol. 2001;  32 390-393
• 8 Baron T H. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis.  Gastrointest Endosc Clin N Am. 2003;  35 102-106
• 9 Giovannini M, Bories E, Moutardier V. et al . Drainage of deep pelvic abscesses using therapeutic echo endoscopy.  Endoscopy. 2003;  35 511-514
• 10 Wiersema M J, Sandusky D, Carr R. et al . Endosonography-guided cholangiopancreatography.  Gastrointest Endosc. 1996;  43 102-106
• 11 Giovannini M, Moutardier V, Pesenti C. et al . Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.  Endoscopy. 2001;  33 898-900
• 12 Puspo K A, Lomoschitz F, Dejaco C. et al . Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series.  Am J Gastroenterol. 2005;  100 1743-1747
• 13 Kahaleh M, Yoshida C, Yeaton P. EUS antegrade pancreatography with gastropancreatic duct stent placement: review of two cases.  Gastroint Endosc. 2003;  58 919-923
• 14 Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUS-cholangiodrainage of the bile duct: report of 4 cases.  Gastroint Endosc. 2003;  57 246-150
• 15 Mallery S, Matlock J, Freeman M L. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases.  Gastroint Endosc. 2004;  59 100-107
• 16 Kahaleh M, Yoshida C, Kane L, Yeaton P. Interventional EUS cholangiography: a report of five cases.  Gastroint Endosc. 2004;  60 138-142
• 17 Will U, Meyer F, Manger T, Wanzar I. Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis.  Endoscopy. 2005;  37 171-173
• 18 Lai R, Freeman M. Endoscopic ultrasound-guided bile duct access for rendezvous ERCP drainage in the setting of intra-diverticular papilla.  Endoscopy. 2005;  37 487-489
• 19 Kahaleh M, Wang P, Shami V. et al . EUS-guided transhepatic cholangiography: report of 6 cases.  Gastrointest Endosc. 2005;  61 307-313
• 20 Kahaleh M, Hernandez A J, Tokar J. et al . Interventional EUS-guided cholangiography: evaluation of a technique in evolution.  Gastrointest Endosc. 2006;  64 52-59