Endoscopic ultrasound-guided biliary drainage in failed endoscopic retrograde cholangiopancreatography: A case series and review of literature

Abstract

Abstract Obstructive jaundice is a common clinical manifestation of malignant biliary obstruction (MBO). Pancreaticobiliary malignancy causes a significant proportion of distal biliary obstructions, most of which are unresectable at the time of diagnosis. Palliative biliary drainage is required in cases of unresectable malignant distal biliary obstruction (MDBO). Surgical, endoscopic, or percutaneous methods can relieve biliary obstruction. Percutaneous transhepatic biliary drainage (PTBD) is the most common alternative method if endoscopic retrograde cholangiopancreatography (ERCP) fails. The complication rate of PTBD and associated comorbidities is high. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has two access routes, i.e., intrahepatic and extrahepatic. The technical and clinical success rate of EUS-BD is high, exceeding 90%. When ERCP fails, the EUS rendezvous approach should be attempted first if papilla is accessible. Transmural drainage is the preferred method if the papilla is inaccessible. For distal and mid-common bile duct obstruction, we perform EUS-guided choledochoduodenostomy (EUS-CDS). For EUS-CDS, one can use either a self-expandable metallic stent (SEMS) or a lumen-apposing metal stent. EUS-BD procedures are technically challenging, and adverse events are common even in expert hands. A multidisciplinary approach is most appropriate for patients with distal MBO who fail ERCP.