Endoscopic ultrasound-guided intervention for inaccessible papilla in advanced malignant hilar biliary obstruction

Abstract

Advanced malignant hilar biliary obstruction (MHBO) with inaccessible papilla poses a significant challenge to endoscopists, as drainage of multiple liver segments may be warranted. Transpapillary drainage may not be feasible in patients with surgically altered anatomy, duodenal stenosis, prior duodenal self-expanding metal stent, and after initial transpapillary drainage, but require re-intervention for draining separated liver segments. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous trans-hepatic biliary drainage are the feasible options in this scenario. The major advantages of EUS-BD over percutaneous trans-hepatic biliary drainage include a reduction in patient discomfort and internal drainage away from the tumor, thus reducing the possibility of tissue or tumor ingrowth. With innovations, EUS-BD is helpful not only for bilateral communicating MHBO but also for non-communicating systems with bridging hilar stents or isolated right intra-hepatic duct drainage by hepatico-duodenostomy. EUS-guided multi-stent drainage with specially designed cannulas and guidewires has become a reality. A combined approach with endoscopic retrograde cholangiopancreatography for re-intervention, interventional radiology, and intraductal tumor ablative therapies has been reported. Stent migration and bile leakage can be minimized with proper stent selection and technique, and stent blocks can be managed with EUS-guided interventions in a majority of cases. Future comparative studies are required to establish the role of EUS-guided interventions in MHBO as rescue or primary therapy.

The Lambda stenting technique: a new approach to address EUS-guided biliary drainage–associated adverse events

“… 7 Despite efforts to prevent stent migration, 8 , 9 several cases of stent migration in EUS-BD have been reported. 10 Additionally, the lumen-apposing stent has been applied, particularly in procedures of EUS-guided gallbladder drainage. 11 Although the presence of flanges on both sides of the stent may reduce the risk of migration, cases have been reported in which stent migration occurred.…”

Comparison of stent patency between EUS-guided hepaticogastrostomy with bridging and endoscopic transpapillary biliary drainage for hilar obstruction

“…However, the EUS-HGS with bridging (EUS-HGSB) method, in which stenting is performed between the left and right bile ducts via the EUS-HGS route, has recently been developed for MHBO, allowing for bilateral drainage without ETBD or percutaneous transhepatic biliary drainage ( Fig. 1 ) 8 9 10 11 12 13 14 15 16 17 18 19 . Currently, only three reports about the EUS-HGSB method, excluding case reports, are available, indicating technical and clinical success rates of 50% to 100% 10 11 12 .…”

Percutaneous transhepatic cholangioscopy combined with endoscopic retrograde cholangiopancreatography for bilateral biliary bridge drainage for malignant biliary obstruction

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Biliary drainage in advanced malignant hilar biliary obstruction (MHBO) is challenging, especially with Bismuth-Corlette III-IV [1]. By placing a bridge stent between the left and right hepatic ducts, the non-communication system in MHBO can be drained, which is potentially a very promising biliary drainage strategy for MHBO [2].

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