Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips

Abstract

Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is not normally indicated for an obstructed right intrahepatic bile duct (IHBD). The technical feasibility and clinical efficacy of a novel technique of EUS-BD for right IHBD obstruction were evaluated. A total of 11 patients underwent drainage using either a left or a right biliary access route. The causes of obstructive jaundice were cholangiocarcinoma (n = 6), pancreatic cancer (n = 3), gastric cancer (n = 1), and colon cancer (n = 1). After placement of an uncovered metal stent to bridge the obstruction, a hepaticogastrostomy was completed using a covered stent. Mean procedure time was 33.9 ± 10.0 minutes. Technical and functional success were achieved in all patients, and no adverse events occurred. This novel method appears to be safe and effective for right IHBD obstruction.

Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel

“…For HGS, a fistula is first created between the left intrahepatic duct and the stomach followed by insertion of a stent. There are also reports of stents placed between the right intrahepatic duct and duodenum, but the procedure is more technically demanding 101. In a small randomised study comparing 25 patients who received HGS and 24 who received CDS, the clinical success of HGS was higher (91% vs 77%) and the adverse events were also slightly higher (20% vs 12.5%), although neither outcome reached statistical significance 102…”

Is EUS-guided drainage a suitable alternative technique in case of proximal biliary obstruction?

“…2–5 However, since the right liver accounts for approximately 60–70% of the hepatocellular mass and EUBD gives access in most cases to the left ducts (except, but randomly, in case of transduodenal EUBD), this technique tends to be limited to distal obstruction, in which all EUBD approaches (transduodenal, transgastric and by transhepatic rendezvous) are in theory equally valid. 4,6,7 The common approach to cases of hilar obstruction after ERCP failure or when access to the major papilla is barred is to refer the patient to the interventional radiologist for a percutaneous transhepatic drainage, in which case left and right liver accesses are available and multiple stenting is possible even for advanced strictures. However, percutaneous drainage is associated with higher morbidity than ERCP and is not recommended in case of ascites and massive one-sided tumor involvement, thus sometimes restricting available access routes.…”

Clinical utility of endoscopic ultrasound‐guided biliary drainage as a rescue of re‐intervention procedure for high‐grade hilar stricture

“…For right hepatic duct obstruction, the echoendoscope was introduced into the duodenal bulb. Using down angle and counter clockwise rotation, the right hepatic bile duct was visualized, as previously described . Then, the right intrahepatic bile duct was punctured using a 19‐G FNA needle (Fig.…”