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

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    What the procedure involves.

    EUS-BD is used as an alternative procedure when ERCP is not possible; ERCP failure occurs in around 5 to 10% of people because of the nature of the obstruction or patient anatomy (which may be altered because of disease progression or previous surgery). EUS-BD is also a minimally invasive alternative to PTBD which is conventionally offered when ERCP has failed. The aim of the procedure is to reduce biliary obstruction and allow the biliary tract to drain.

    EUS-BD may be done under conscious sedation or general anaesthesia. It involves inserting an echoendoscope through the mouth and oesophagus into the stomach or duodenum. Using ultrasound guidance, the biliary tract is punctured with a needle. A contrast agent may be injected to enhance imaging.

    A guidewire is then passed into the biliary tract at the site of the puncture, which is dilated to create a fistula. Finally, a metal or plastic stent is deployed into the biliary tract to allow for biliary drainage into the stomach or small intestine. Stent delivery systems may also be used to do EUS-BD without needle puncture, dilation or insertion of guidewire.

    EUS-BD can be done using several different techniques and stents deployed via multiple access routes. The two most common techniques, EUS-CDS and EUS‑HGS, both use a transluminal approach. In EUS-CDS, the extrahepatic bile duct is punctured and stent deployed from the duodenal bulb. In EUS-HGS, the left hepatic duct is punctured and stent deployed via the stomach.

    Stents may also be deployed using a transpapillary approach in which the guidewire is passed into the duodenum. In EUS-AGS, the stent is placed across the biliary obstruction. In EUS-RV, the echoendoscope is swapped with an ERCP duodenoscope after placement of the guidewire and a conventional ERCP is done before stent placement. The choice of technique is dependent on the cause of biliary obstruction and patient anatomy.