Skip to main content
  • Letter to the Editor
  • Open access
  • Published:

Biliary drainage guided by endoscopic ultrasonography is a doable objective

Abstract

The therapeutic usage of EUS is being developed. EUS-guided biliary drainage (EUSBD) is a recognized viable replacement for percutaneous transhepatic biliary drainage (PTBD) in severe cases with the obstructive biliary disease having ERCP failure due to a failure in cannulation or those with surgically altered anatomies, such as hepatico-jejunal anastomosis following Billroth II reconstruction, Roux-en-Y limb, Whipple procedure, or Roux-en-Y gastric bypass, or cases with inaccessible papilla because of severe duodenal inflammatory structure.

To the editor

EUS-guided biliary drainage was reported in 2001 by Giovannini et al. Following this report, many groups reported the efficacy of EUS-BD as an alternative biliary drainage method after unsuccessful ERCP [1]. Many reviews have been published in the last 10 years thoroughly explained various EUS-BD techniques and reported efficacy and safety of that technique.

A significant study by Pawa R. et al. [2] conducted on endoscopic ultrasound-guided biliary drainage (EUS-BD) provides a novel and promising approach, particularly in challenging instances with obstructive biliary disease.

Endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERC-PBD) is the frequently used approach for handling biliary obstruction. However, it has a wide variety of post-procedure problems and specific technical challenges [3]. Percutaneous transhepatic biliary drainage (PTBD) was the only choice for severe cases with biliary drainage because of anatomical abnormalities or inaccessible papilla [4]; however, it is involved in several adverse effects, including catheter dislocation, bleeding, infection, acute cholangitis, biliary leakages, and pneumothorax. Additionally, it is typically uncomfortable for patients because of the external drainage catheter, and it is not recommended with multiple liver metastasis or ascites [5, 6].

Recently, endoscopic ultrasound (EUS) has a superior modality over conventional noninvasive imaging techniques such as computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), transabdominal ultrasound, and magnetic resonance imaging (MRI) in being a diagnostic tool and playing a significant therapeutic role as well [7].

Several EUS-BD methods described in the literature in this clinical setting are based on the clinical case, the access to the biliary tree, and the obstruction location [8] like EUS-guided choledochoduodenostomy, EUS-guided rendezvous, EUS-guided hepaticogastrostomy, EUS-directed transgastric ERCP, and EUS-guided gallbladder drainage. EUS provides insights about biliary obstructions, allowing for immediate access to the biliary tree even in case of surgically changed anatomy or duodenal invasion [9]. Thus, it is agreed in being potential alternatives for percutaneous biliary drainage (PTBD) and surgical bypass [2].

Comparing PTBD and EUS-BD in a meta-analysis including 483 patients with malignant biliary obstruction has shown that EUS-BD was associated with higher clinical success, a lower re-intervention rate, and decreased adverse events (AEs) when compared with PTBD [9]; moreover, another meta-analysis confirmed a cumulative success rate of 94.71% and adverse events of 23.32 % for EUS-BD [10].

It is noteworthy that the average rate of adverse events associated with EUS-BD has been found to range between 17 and 18.9% [11, 12] with a lower risk of pancreatitis than ERCP. This may be because EUS-guided transluminal biliary drainage avoids traumatic papillary manipulation, which can result in acute pancreatitis [3]. Additionally, EUS-BD could be challenging in terms of determining the optimal drainage strategy and stent type (self-expanding metallic stent [SEMS] plastic vs. stent [PS]). Also, patients with potentially resectable biliary tumors may require preoperative biliary drainage; thus, palliative endoscopic stent placement and endoscopic biliary drainage (EBD) are some of the most suitable procedures [13]. Additionally, other criteria influencing the optimum stent selection include the degree of ductal dilatation, the indication (malignant vs. benign), the ability of the wire to traverse the anastomosis, the patient’s surgical indication, and the length of the fistula tract [14].

Additionally, the combination of EUS-BD and ERCP methods may be another reasonable solution for biliary drainage, as they both have a low likelihood of biliary reintervention and a high technical success rate [15]. Finally, the optimum technique and accessible route are still debatable and are dependent on various criteria, including the endoscopist’s experience, anatomical accessibility, and procedure indication.

EUS-guided biliary drainage was first reported in Egypt since 2013. In 2019, an Egyptian multicenter study has been published in Therapeutic Advances in Gastrointestinal Endoscopy [16]. In the last 2 years, EUS-BD became widely used in many centers in Egypt.

In conclusion, EUS-BD is a potential replacement for ERCP and PTBD in difficult biliary drainage cases; it has a high success rate, fewer reinterventions, and decreased adverse effects, especially when conducted at advanced endoscopy centers. However, additional studies on the efficacy of EUS-guided biliary drainage in severe cases with biliary disease are required.

Availability of data and materials

Not applicable.

References

  1. Chavalitdhamrong D, Draganov PV (2012) Endoscopic ultrasound-guided biliary drainage. World J Gastroenterol 18(6):491–497. https://doi.org/10.3748/wjg.v18.i6.491

    Article  PubMed  PubMed Central  Google Scholar 

  2. Pawa R, Pleasant T, Tom C, Pawa S (2021) Endoscopic ultrasound-guided biliary drainage: are we there yet? World J Gastrointest Endosc 13(8):302–318

    Article  Google Scholar 

  3. Jin Z, Wei Y, Lin H et al (2020) Endoscopic ultrasound-guided versus endoscopic retrograde cholangiopancreatography-guided biliary drainage for primary treatment of distal malignant biliary obstruction: a systematic review and meta-analysis. Dig Endosc 32(1):16–26. https://doi.org/10.1111/den.13456

    Article  PubMed  Google Scholar 

  4. Salerno R, Davies SEC, Mezzina N, Ardizzone S (2019) Comprehensive review on EUS-guided biliary drainage. World J Gastrointest Endosc 11(5):354–364. https://doi.org/10.4253/wjge.v11.i5.354

    Article  PubMed  PubMed Central  Google Scholar 

  5. Yarmohammadi H, Covey AM (2016) Percutaneous biliary interventions and complications in malignant bile duct obstruction. Chin Clin Oncol 5:68. https://doi.org/10.21037/cco.2016.10.07 PMID: 27829281

    Article  PubMed  Google Scholar 

  6. Nennstiel S, Weber A, Frick G, Haller B, Meining A, Schmid RM, Neu B (2015) Drainage-related complications in percutaneous transhepatic biliary drainage: an analysis over 10 years. J Clin Gastroenterol 49:764–770. https://doi.org/10.1097/MCG.0000000000000275 PMID: 25518004

    Article  PubMed  Google Scholar 

  7. Saraireh HA, Bilal M, Singh S (2017) Role of endoscopic ultrasound in liver disease: where do we stand in 2017? World J Hepatol 9(24):1013–1021. https://doi.org/10.4254/wjh.v9.i24.1013

    Article  PubMed  PubMed Central  Google Scholar 

  8. Nunes N, Flor de Lima M, Caldeira A et al (2021) GRUPUGE perspective: endoscopic ultrasound-guided biliary drainage. GE Port. J Gastroenterol 28(3):179–184. https://doi.org/10.1159/000510026

    Article  Google Scholar 

  9. Paik WH, Lee TH, Park DH et al (2018) EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: a multicenter randomized clinical trial [published correction appears in Am J Gastroenterol. 2018 Oct;113(10):1566]. Am J Gastroenterol 113(7):987–997. https://doi.org/10.1038/s41395-018-0122-8

    Article  PubMed  Google Scholar 

  10. Wang K, Zhu J, Xing L, Wang Y, Jin Z, Li Z (2016) Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review. Gastrointest Endosc 83(6):1218–1227. https://doi.org/10.1016/j.gie.2015.10.033

    Article  PubMed  Google Scholar 

  11. Dhir V, Isayama H, Itoi T et al (2017) Endoscopic ultrasonography-guided biliary and pancreatic duct interventions. Dig Endosc 29(4):472–485. https://doi.org/10.1111/den.12818

    Article  PubMed  Google Scholar 

  12. Khan MA, Akbar A, Baron TH et al (2016) Endoscopic ultrasound-guided biliary drainage: a systematic review and meta-analysis. Dig Dis Sci 61(3):684–703. https://doi.org/10.1007/s10620-015-3933-0

    Article  PubMed  Google Scholar 

  13. ASGE Standards of Practice Committee, Jue TL, Storm AC et al (2021) ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc 93(2):309–322.e4. https://doi.org/10.1016/j.gie.2020.07.063

    Article  Google Scholar 

  14. Tyberg A, Desai AP, Kumta NA, Brown E, Gaidhane M, Sharaiha RZ, Kahaleh M (2016) EUS-guided biliary drainage after failed ERCP: a novel algorithm individualized based on patient anatomy. Gastrointest Endosc 84:941–946. https://doi.org/10.1016/j.gie.2016.05.035 PMID: 27237786

    Article  PubMed  Google Scholar 

  15. Kongkam P, Orprayoon T, Boonmee C et al (2021) ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: a multicenter observational open-label study. Endoscopy. 53(1):55–62. https://doi.org/10.1055/a-1195-8197

    Article  PubMed  Google Scholar 

  16. Altonbary AY, Galal A, El-Nady M, Hakim H (2019) Endoscopic ultrasound guided biliary drainage: a multicenter retrospective experience of a technique slowly gaining acceptance in Egypt. Therapeut Adv Gastrointest Endosc. https://doi.org/10.1177/2631774519889456

Download references

Acknowledgements

We would like to acknowledge our great Kasr Al Ainy Hospital and its workers, nurses, and staff members.

Core tip

Considerable difficulties exist in handling severe cases with obstructive biliary disease and identifying benign from malignant etiology to avoid potentially fatal errors. It is aimed to discuss the standard diagnostic and potential therapeutic roles of EUS in identifying and handling various severe cases with obstructive biliary illness using endoscopic ultrasound-guided biliary drainage (EUS-BD) methods.

Funding

Authors received no funding for this study.

Author information

Authors and Affiliations

Authors

Contributions

AA designed the research and wrote the letter, and MW revised the letter. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Abeer Abdellatef.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Abdellatef, A., Wifi, MN. Biliary drainage guided by endoscopic ultrasonography is a doable objective. Egypt J Intern Med 34, 61 (2022). https://doi.org/10.1186/s43162-022-00151-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s43162-022-00151-7