Endoscopic Ultrasound Guided Biliary Drainage in Malignant Distal Biliary Obstruction

Abstract

Malignant biliary obstruction (MBO) is a challenging medical problem that often negatively impacts the patient’s quality of life (QoL), postoperative complications, and survival rates. Endoscopic approaches to biliary drainage are generally performed by ERCP or, in selected cases, with a percutaneous transhepatic biliary drainage (PTBD). Recent advances in therapeutic endoscopic ultrasound (EUS) allow drainage where previous methods have failed. EUS has evolved from a purely diagnostic technique to one that allows a therapeutic approach in the event of ERCP failure in distal MBO. Moreover, the introduction of dedicated accessories and prostheses for EUS-guided transmural biliary drainage (EUS-BD) made these procedures more successful with regard to technical success, clinical outcomes and reduction of adverse events (AEs). Finally, lumen-apposing metal stents (LAMS) have improved the therapeutic role of the EUS. Subsequently, the electrocautery enhanced tip of the LAMS (EC-LAMS) allows a direct access of the delivery system to the target lumen, thereby simplifying and reducing the EUS-BD procedure time. EUS-BD using LAMS and EC-LAMS has proven effective and safe with a low rate of AEs. This review aims to evaluate biliary drainage techniques in malignant obstruction, focusing on the role of EUS biliary drainage by LAMS.

Endoscopic ultrasound‐guided gallbladder drainage as a first approach for jaundice palliation in unresectable malignant distal biliary obstruction: Prospective study

“…We utilized a different LAMS, the Hot-Spaxus stent, which has been reported to have a high technical performance in EUS-GBD. [17][18][19][20][21] As in the previous studies, technical success was achieved in all patients, demonstrating GBD in this setting to be a very safe procedure, mostly ensured by skills previously acquired by endosonographers in the context of acute cholecystitis in high-risk surgical patients. Moreover, in the clinical scenario of the present study the GB is usually distended by the presence of DMBO and without inflammatory changes, such as thickened GB walls or peri-GB fluid/collection, thus making the drainage procedure easier than in the acute setting.…”

“…The cystic duct had to be patent on CT/MRI, which was subsequently rechecked during EUS done to perform EUS‐GBD that resulted in exclusion of three additional patients, leading to a total of 37 patients evaluated. We utilized a different LAMS, the Hot‐Spaxus stent, which has been reported to have a high technical performance in EUS‐GBD 17–21 . As in the previous studies, technical success was achieved in all patients, demonstrating GBD in this setting to be a very safe procedure, mostly ensured by skills previously acquired by endosonographers in the context of acute cholecystitis in high‐risk surgical patients.…”

Updates in Diagnosis and Endoscopic Management of Cholangiocarcinoma

“…Even if ERCP is the therapeutic option of choice in non-surgical patients, EUS-BD can be an option when ERCP is not feasible [ 83 ]. EUS-guided biliary drainage (EUS-BD) has been used for unresectable CCA with a technical and clinical success rate of over 90% and over 70%, respectively [ 82 ].…”

“…LAMS represents a new type of fully covered self-expandable metal stent which is mounted using a delivery system with an electrocautery distal tip, which facilitates the direct access to the biliary system [ 85 , 86 ]. The technique was first described in 2001 by Giovannini [ 83 ].…”

Comparison between Endoscopic Ultrasound‐Guided Antegrade and Transluminal Stent Implantation in Distal Malignant Biliary Obstruction after Failed ERCP

“…The EUS-BD technique includes transluminal (TL) biliary stent placement, EUS-guided antegrade transpapillary (or transanastomotic) stenting, and EUS-guided rendezvous (RV) approach [3][4][5]. Though the RV method can provide a physiologic anatomic pathway for drainage, it may fail due to inaccessible papilla or failure to advance guidewire through the stricture [6].…”