Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Abstract

Main Recommendations 1 ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2 ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3 ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4 ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5 ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6 ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7 ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8 ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

“…4 Biliary and pancreatic duct drainage EUS-guided drainage of the biliary system (EUS-BD) or the pancreatic ducts (EUS-guided PD drainage) may be required when conventional ERCP fails. How these procedures compare with percutaneous and surgical alternatives, and when they should be undertaken is discussed in greater detail in the ESGE guideline on therapeutic EUS [1].…”

“…Although no formal comparison exists between these three approaches, it is generally accepted that RV-ERP may hold significant advantages over antegrade or transmural drainage with regards to safety and efficacy [69,[71][72][73]. The latter techniques are therefore only recommended in patients where RV-ERP fails or is not technically feasible [1,68,72].…”

“…6.2 Key question 10: How should EDGE procedures be performed? EUS-directed transgastric ERCP (EDGE) can be offered to patients with RYGB in expert centers in an attempt to overcome the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP [1]. This section is aimed at providing technical guidance regarding EDGE, the timing of subsequent ERCP, and management following successful therapy.…”

“…Endoscopic ultrasound (EUS) enables several therapeutic interventions in the pancreaticobiliary and gastrointestinal (GI) tract. A recent European Society of Gastrointestinal Endoscopy (ESGE) Guideline on therapeutic EUS provided an extensive overview of the indications and outcomes of these procedures [1]. EUS-guided management of fluid collections in acute necrotizing pancreatitis has been discussed in a previous ESGE guideline [2].…”

“…EUS-guided management of fluid collections in acute necrotizing pancreatitis has been discussed in a previous ESGE guideline [2]. This review of the technical aspects of therapeutic EUS was commissioned by the ESGE to complement the guideline [1] focusing on procedural features and management of adverse events (AEs).…”