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    The content on this page is not current guidance and is only for the purposes of the consultation process.

    Interventional procedure overview of endoscopic ultrasound-guided biliary drainage for biliary obstruction

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    Existing assessments of this procedure

    A guideline on the use of therapeutic endoscopic ultrasound-guided procedures was published by the ESGE in 2022 (van der Merwe 2022). The ESGE made the following recommendations regarding EUS-BD:

    • 'ESGE recommends the use of EUS-BD over PTBD after failed ERCP in malignant distal biliary obstruction when local expertise is available' (strong recommendation, moderate quality evidence).

    • ESGE recommends ERCP for primary drainage of malignant distal biliary obstruction, but EUS-guided biliary drainage could also be used in this setting for inoperable patients at high volume expert centres (strong recommendation, moderate quality evidence).

    • 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 centres (weak recommendation, moderate quality evidence).

    • ESGE suggests EUS-BD in malignant post-surgical biliary obstruction and a long biliary limb with dilated intrahepatic bile ducts (weak recommendation, low quality evidence).

    • ESGE suggests EUS-BD only after failed enteroscopy-assisted ERCP in the management of benign post-surgical biliary obstruction or common bile duct stones (weak recommendation, low quality evidence).

    • ESGE suggests an EUS-guided rendezvous technique after a second failed ERCP in benign biliary disease and normal gastrointestinal anatomy in high volume expert centres (weak recommendation, low quality evidence).

    A consensus statement published in 2020 by the Journal of Gastroenterology and Hepatology (Nakai 2020) made the following statement about EUS-BD:

    Where expertise is available, EUS-BD may be an option in these situations: (i) failed ERCP, (ii) Post-surgical anatomy and (iii) difficult biliary cannulation (strong recommendation, moderate level of evidence.

    An additional consensus statement published in 2018 on the optimal management in interventional EUS procedures (Teoh 2018) made several recommendations relating to EUS-BD, including the following:

    • EUS-BD is recommended as the procedure of choice for biliary drainage in patients with failed ERCP if expertise is available (appropriate level of agreement, high level of evidence)

    • EUS-BD is an alternative procedure to obtain biliary drainage in patients with altered postoperative anatomy or duodenal stenosis precluding ERCP if expertise is available (appropriate level of agreement, moderate level of evidence)

    • In patients with distal common bile duct obstruction, transduodenal and transhepatic approaches for EUS-BD are used (appropriate level of agreement, moderate level of evidence)

    • A transhepatic approach to EUS-BD is recommended for hilar blocks (appropriate level of agreement, low level of evidence)

    • Multidisciplinary support including interventional radiologist, surgeons and anaesthesiologist to prevent and manage complications is recommended in centres performing EUS-BD (appropriate level of agreement, very low level of evidence)

    • Training of EUS-BD should be done at expert centres with facilities and expertise in EUS, ERCP and PTBD (appropriate level of agreement, very low level of evidence)

    • Training in EUS-BD should only commence in those endoscopists experienced in EUS-FNA, wire manipulation techniques and biliary stent placement (appropriate level of agreement, very low level of evidence)