EUS GUIDED BILIARY DRAINAGE – TECHNICAL VARIANTS

Description:

We present the video of 4 cases of obstructive jaundice solved with endoscopic ultrasonography guided biliary drainage. In 3 of these patients, it was not possible to access the second duodenal portion and/or to visualize the papilla major due to the presence of pancreatic head adenocarcinomas with subsequent duodenal invasion, which led to choledochoduodenostomies in two of them, and the placement of a anterograde transpapillar metal stent through the duodenal bulb in the other patient.

The fourth patient had obstructive jaundice secondary to metastatic hilar adenopathies, due to an advanced gastric neoplasia with gastro outlet obstruction. Biliary drainage was performed through a hepatogastrostomy.

All procedures were performed with technical and clinical success (resolution of jaundice) and with no relevant adverse events related to the procedure. None of the patients presented biliary obstruction recurrence until their death.

Motivation:

ERCP stent placement is a minimally invasive 1st line technique for the treatment of biliary obstructions. Despite their high safety and efficacy, there are patients where this is not possible, even when performed by experienced ERCP endoscopists. The majority of these cases are related duodenum invading tumors, not allowing the duodenoscope to access the 2nd duodenal portion or recognition of the major papilla. In these situations biliary drainage by echoendoscopy, is a valid option in centers with experienced ERCP endoscopists/echoendoscopy and adequate material and human resources. In this video we intend to illustrate 3 variants of this technique (choledochoduodenostomy, hepatogastrostomy, anterograde transpapillary prosthesis), whose worldwide experience is still limited, given the high level of difficulty associated.