Drainage of the right liver under EUS guidance: A bridge technique allowing drainage of the right liver through the left liver into the stomach or jejunum

Abstract

Background and Objective: EUS-guided biliary drainage is now comparable to percutaneous drainage. This technique can be used in cases of complex drainage of the hilum, mainly for salvage therapy to drain the left liver. In cases of inaccessible papilla or altered anatomy, EUS-guided biliary drainage for hilar stenosis of the liver could be used as the first approach. However, this technique has limited applicability for the right liver. In this feasibility study, we reported drainage of the right liver using the bridge technique and hepaticogastrostomy. Patients and Methods: This retrospective study was based on a prospective registry from January 2013 to February 2017. Patients with inaccessible papilla due to altered anatomy or duodenal invasion and drainage under EUS guidance and bridge technique without previous biliary drainage were included in the study. The bridge technique was used to place an uncovered biliary stent between the right and left liver. The left liver was drained with a hepaticogastrostomy. Results: Twelve patients were included in the study. Stenosis was Type II for nine, IIIA for two, and Type IV for one patient. Technical and clinical success was 100% and 83%, respectively. Morbidity was 33% (four patients), including three with abdominal pain managed conservatively and one with a percutaneous salvage drainage. Postoperative mortality was 8% (uncontrolled sepsis). The mean survival was 6 months. Chemotherapy could be administered in 70% (seven) patients in cases of clinical success. Conclusion: The bridge technique under EUS guidance could be a first alternative for draining malignant hilar stenosis in cases of the inaccessible papilla.

Feasibility of EUS-guided hepaticogastrostomy for inoperable malignant hilar biliary strictures

“…In this situation, several studies have demonstrated the feasibility of the bridge technique. [ 24 25 ] Another indication for EUS-HGS alone as the initial drainage method is complex hilar strictures associated with significant invasion of the hilum and right liver since this situation is associated with a high risk of ERCP failure. The advantage of EUS-HGS is that this method can be applied as a rescue technique after ERCP failure,[ 8 9 ] early in the case of cholangitis or at a distance when there is disease progression [ Figure 3 ].…”

Outcomes and limitations of endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction

“…Bismuth type II–IV cholangiocarcinoma was a negative predictive factor for endoscopic procedure efficacy and was not related to the lack of adequate drainage in our patients. In all patients whose malignant lesion involved the liver hilum, access to the right intrahepatic duct was gained via the stricture being splinted by a stent introduced into the left intrahepatic duct via the stomach, as previously described [ 29 , 30 ]. The presence of metastatic lesions in the liver and high blood bilirubin levels also had a negative effect on treatment outcomes.…”

Outcomes and Limitations of Endoscopic Ultrasound-guided Hepaticogastrostomy in Malignant Biliary Obstruction

“…In all patients whose malignant lesion involved the liver hilum, access to the right intrahepatic duct was gained via the stricture being splinted by a stent introduced into the left intrahepatic duct via the stomach, as previously described. [29,30] The presence of metastatic lesions in the liver and high blood bilirubin levels also had a negative effect on treatment outcomes. Both ndings might have had a common denominator.…”