Skip Navigation
Skip to contents

Clin Endosc : Clinical Endoscopy

Search
Advanced Search
OPEN ACCESS
mobile search button mobile menu button

Articles

Page Path
HOME > Clin Endosc > Volume 52(3); 2019 > Article
Focused Review Series: Expanding Indication: Interventional Endoscopic Management for Pancreaticobiliary Diseases Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction
Yousuke Nakai1orcid, Hirofumi Kogure1, Hiroyuki Isayama1,2, Kazuhiko Koike1
Clinical Endoscopy 2019;52(3):220-225.
DOI: https://doi.org/10.5946/ce.2018.094
Published online: November 29, 2018

1Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan

2Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan

Correspondence: Yousuke Nakai Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan Tel: +81-3-3815-5411, Fax: +81-3-5800-9801, E-mail: ynakai-tky@umin.ac.jp
• Received: June 1, 2018   • Revised: June 26, 2018   • Accepted: June 27, 2018

Copyright © 2019 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • 8,149 Views
  • 344 Download
  • 44 Web of Science
  • 44 Crossref
  • 44 Scopus
prev next
Full Article

Download PDF Download PDF

  • Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO) and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneous transhepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary stricture and internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUS-guidance include a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. The aim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches such as endoscopic transpapillary biliary drainage and PTBD.
  • Keywords: Biliary drainage; Endosonography; Hilar biliary obstruction; Neoplasms
Patients with hilar malignant biliary obstruction (MBO) often present at an unresectable stage. Endoscopic transpapillary biliary drainage (EBD) is the current standard of care to relieve jaundice. Multiple metallic stent (MS) placement is often performed but is technically demanding and percutaneous transhepatic biliary drainage (PTBD) is sometimes needed after technical or clinical failure by endoscopic approach [1].
Endoscopic ultrasound-guided biliary drainage (EUSBD) for MBO is being increasingly reported but is mostly performed for distal MBO and only by experts [2,3]. Since it has the potential advantage of not traversing the biliary stricture, it may play a role in the management of hilar MBO as well [4]. However, data on EUS-BD for hilar MBO are still limited. In this review article, we will overview EUS-BD for hilar MBO.
In unresectable hilar MBO, biliary drainage can be achieved either by EBD or PTBD. Although a systematic review [5] showed a better success rate of PTBD, EBD is the current standard of care because PTBD impairs the quality of life in general whereas EBD does not. There are some options for endoscopic management of hilar MBO: Plastic stent (PS) vs. MS [6,7] and unilateral vs. bilateral stenting [8,9].
MS is shown to have longer stent patency than PS in randomized controlled trials (RCTs) [6,7]. Some reports have demonstrated the association of liver volume with adequate biliary drainage. One study [10] showed that 33% of the liver volume should be drained in cases that have preserved liver function to obtain adequate biliary drainage, whereas 50% of the liver volume should be drained in those with impaired liver function. In another study, longer survival rates were observed in cases of hilar MBO after draining ≥50% of the liver volume [11]. To drain ≥50% the liver volume, bilateral biliary drainage is necessary in most cases. A recent Korean RCT [12] clearly demonstrated the superiority of bilateral MS placement over unilateral MS placement. Bilateral MS placement showed a longer duration of stent patency (252 days vs. 139 days, p<0.01) and statistically non-significant but clinically significant differences in survival (270 days vs. 178 days, p=0.053).
The recent development of MS suitable for hilar stenting via a thin delivery system allows easy bilateral stent placement, either by using a stent-in-stent method [13,14] or a sideby-side method [15]. These MS also allow re-interventions after recurrent biliary obstruction (RBO) following bilateral stent placement [16]; nevertheless, the procedure can be technically difficult or even impossible. When endoscopic re-intervention fails, PTBD may be necessary to relieve jaundice or cholangitis, which impairs the quality of life due to the indwelling drainage tube. Technical and clinical hurdles of transpapillary multiple MS placement for hilar MBO are caused by the complexity of the stent configuration at the hepatic hilum. To overcome the limitations of conventional approaches such as EBD and/or PTBD, another novel approach for hilar MBO has been long awaited.
EUS-BD is being increasingly utilized in the management of MBO in cases of failed or difficult endoscopic retrograde cholangiopancreatography (ERCP). In addition to obtaining biliary access after failed ERCP, EUS-BD does not traverse the biliary stricture, which may provide an advantage in the management of hilar MBO. There are two approaches used by EUS-BD, intrahepatic and extrahepatic, but the intrahepatic approach is mandatory for hilar MBO.
Indications and contraindications of EUS-BD for hilar MBO are shown in Table 1. Theoretically, EUS-BD can be indicated for any hilar MBO but the current indications are failed ERCP, surgically altered anatomy, and failed re-interventions for occlusion of transpapillary placed stents. Contraindications are severe coagulopathy, massive ascites, intervening vessels, and unstable conditions unfit for endoscopic procedures. In such cases, EUS-BD might have higher risks of morbidity or mortality due to complications such as bleeding, bile leak, and stent migration. Furthermore, despite reports of a high technical success rate and acceptable adverse event rate, expertise is necessary for EUS-BD as dedicated devices for EUS-BD are currently limited.
EUS-guided hepaticogastrostomy (EUS-HGS) is one of the most common EUS-BD procedures via an intrahepatic approach [17]. In EUS-HGS, biliary access to segment 2 or 3 is established via the cardia or lesser curvature of the stomach under EUS guidance, and a stent is placed from B2 or B3 to the stomach. In hilar MBO, therefore, biliary drainage of the left biliary system alone is achieved by EUS-HGS, leaving the right biliary system undrained with potential risks of inadequate biliary drainage or segmental cholangitis.
As shown in transpapillary stenting, bilateral drainage can potentially lead to better clinical outcomes for hilar MBO. The approaches to obtain bilateral drainage with EUS-BD include a bridging method, EUS-guided hepaticoduodenostomy (EUS-HDS), and a combined EUS and ERCP approach (Fig. 1).
The bridging method [18] employs a left intrahepatic bile duct (IHBD) access similar to conventional EUS-HGS. After obtaining biliary access from the stomach to the left IHBD using a 19-gauge fine needle aspiration needle and a guidewire, the needle is replaced by a standard catheter and a guidewire is advanced through the hilar stricture into the right IHBD. In difficult cases, a steerable catheter and a hydrophilic guidewire are helpful to pass the hilar stricture. An uncovered bridging MS with a thin delivery system is placed across the hilar stricture, followed by a covered MS placement from the left IHBD to the stomach, as seen with conventional EUS-HGS. During this bridging method, guidewire passage or stent deployment to the right biliary system through the hilar stricture can be technically challenging depending on the angle of left and right hepatic duct confluence. In technically difficult cases, a prolonged procedure time can increase the risk of bile leak and sequential bridging stent placement can be an option. A conventional HGS stent is placed in the left IHBD in the first session and after fistula maturation of the HGS, a bridging stent placement can be attempted by cannulating through the HGS stent (Fig. 2).
EUS-HDS [18,19] employs a right IHBD access from the duodenum, which is a complement of EUS-HGS to the left IHBD. However, EUS-HDS procedures are performed only in a few expert centers and therefore, reports are limited. Ogura et al. [18] reported a locking method with a combination of uncovered and covered MSs to prevent stent migration but the use of a PS dedicated to EUS-BD [20] was also reported. Given the limited number of reports, the best technique of EUS-HDS has not been established thus far.
In high-grade hilar MBO, a combined EUS and ERCP approach proposed by Park [21] can be a treatment option. In this approach, EUS-HGS to the left IHBD and transpapillary stenting to the right IHBD are performed (Fig. 3). This approach is feasible due to two anatomical reasons. First, as observed with resectable hilar MBO, the left hepatic duct is longer than the right hepatic duct, allowing drainage of the whole left biliary system by a single EUS-HGS stent. Second, the right IHBD is more prone to cancer invasion especially in cases with gallbladder cancer, necessitating multiple stenting of the right biliary system. Although multiple stenting in EUS-BD is theoretically possible, transpapillary multiple stent placement is more established. Therefore, a combination of simple EUS-HGS in the left IHBD and multiple stenting in the right IHBD can achieve >50% biliary drainage with technical feasibility.
Table 2 summarized data on EUS-BD for hilar MBO [18-20,22-29]. The overall technical success rate was 98% and the overall adverse event rate was 8%. However, the overall clinical success rate was 77%, which was lower than previously reported in a systematic review of EUS-BD [30]. Clinical outcomes were comparable between the initial EUS-BD procedure and the rescue EUS-BD procedure after failed transpapillary drainage. However, the number of cases was too small and the procedures were performed only by experts. Therefore, publication bias was possible especially with respect to adverse events. A relatively low clinical success rate suggests that appropriate biliary drainage for unresectable hilar MBO is difficult in any approach: ERCP, EUS, or PTBD. The available literature was focused on short-term outcomes and long-term outcomes such as RBO and its re-interventions were not investigated. Future studies should be focused on patient selection or on treatment selection for better management of hilar MBO.
Transpapillary stenting is still the standard of care for unresectable hilar MBO, and PTBD is often a rescue procedure for failed endoscopic management. As described above, EUS-BD has a definite role in the management of hilar MBO. The advantages and disadvantages are summarized in Table 3. Overall, EUS-BD has a common advantage of both transpapillary stenting and PTBD, namely, a single session internal drainage without crossing the biliary stricture. Internal drainage maintains the quality of life and drainage without crossing the stricture potentially allows longer stent patency.
First of all, the number of reported cases is small. Although the rate of technical success is high, most studies were reported by experts and publication bias may exist. Theoretically, EUS-BD provides better stent patency but long-term outcomes are unclear. Given the improved survival in cases of biliary malignancy, many patients with unresectable hilar MBO need re-intervention for RBO. Endoscopic re-interventions through the EUS-BD route are often possible but PTBD is sometimes necessary to control cholangitis after complex biliary drainage procedures. In addition, the rate of adverse events was only 8% in our review but the intrahepatic approach reportedly had a higher adverse event rate compared to the extrahepatic approach [31]. Finally, technical expertise for performing EUS-BD is not always available in most centers. In such situations, if urgent drainage for cholangitis is necessary, a PTBD can be temporarily placed and conversion from PTBD to EUS-BD can be performed at a later stage [32]. Overall, the evidence regarding these issues is limited and further investigation is warranted.
In conclusion, EUS-BD can be a promising treatment option for unresectable hilar MBO, both as the initial and the rescue procedure. Standardization of procedures as well as development of dedicated devices are necessary to establish the role of EUS-BD in the management of hilar MBO. Future RCTs comparing EUS-BD with EBD or PTBD are warranted to confirm the role of EUS-BD for managing hilar MBO.
Fig. 1.
Techniques of bilateral endoscopic ultrasound-guided biliary drainage. (A) Bridging method. (B) Endoscopic ultrasound-guided hepaticoduodenostomy. (C) Combined endoscopic ultrasound-guided hepaticogastrostomy and transpapillary stenting.
ce-2018-094f1.jpg
Fig. 2.
Bridging method. (A) Endoscopic ultrasound-guided hepaticogastrostomy was performed during the first session. (B) A bridging stent was placed during the second session.
ce-2018-094f2.jpg
Fig. 3.
Combined endoscopic ultrasound-guided hepaticogastrostomy and transpapillary stenting. (A) Endoscopic ultrasound-guided hepaticogastrostomy was performed during the first session. (B) Transpapillary multiple stent-in-stent placement was performed during the second session.
ce-2018-094f3.jpg
Table 1.
Current Indications and Contraindications of Endoscopic Ultrasound-Guided Biliary Drainage for Hilar Malignant Biliary Obstruction
Indications
 Failed ERCP
 Surgically altered anatomy i.e., Roux-en-Y reconstruction
 Failed re-intervention for transpapillary stent occlusion
Contraindications
 Severe coagulopathy
 Massive ascites
 Intervening vessels including collateral vessels
 Unstable conditions unfit for endoscopic procedures

ERCP, endoscopic retrograde cholangiopancreatography.

Table 2.
Data on Endoscopic Ultrasound-Guided Biliary Drainage for Hilar Malignant Biliary Obstruction
Study n Initial/rescue Stent Drainage method Technical success Clinical success Adverse events
Bories et al. (2007) [22] 4 Initial PS HGS 4 4 1 stent clogging
Ogura et al. (2014) [23] 1 Initial UMS+CMS Bridging 1 N/A N/A
Ogura et al. (2015) [18] 11 Initial/Rescue UMS+CMS 4 HDS, 7 Bridging 11 N/A 0
Prachayakul et al. (2015) [24] 1 Initial UMS+CMS Bridging 1 1 0
Moryoussef et al. (2017) [25] 18 Initial UMS+CMS 14 HGS, 3 Bridging 17 13 3
Park et al. (2010) [26] 3 Rescue CMS HGS 3 3 0
Park et al. (2013) [19] 2 Rescue CMS HDS 2 2 0
Minaga et al. (2017) [27] 30 Rescue CMS or PS 28 HGS, 2 HDS 29 22 3 bile peritonitis
Ogura et al. (2017) [28] 10 Rescue CMS 8 HGS, 2 HDS 10 9 0
Kanno et al. (2017) [29] 7 Rescue CMS HGS 7 4 0
Mukai et al. (2017) [20] 1 Rescue PS HDS 1 N/A 0
Overall 88 98% (86/88) 77% (58/75) 8% (7/87)

CMS, covered metal stent; HDS, hepaticoduodenostomy; HGS, hepaticogastrostomy; N/A, not available; PS, plastic stent; UMS, uncovered metal stent.

Table 3.
Advantages and Disadvantages of EUS-BD
EUS-BD EBD PTBD
Advantage A single step internal drainage Long term data available High technical success rate
Simplicity at the hilum: possible longer patency Possible tube rinse for clogging
Disadvantage No long term data Technical difficulty for multiple stenting Impaired QOL
Special technique necessary for right IHBD approach Complexity at the hilum High AE rate and re-intervention rate
Contraindications: ascites, coagulopathy Chance of Post-ERCP pancreatitis Contraindications: ascites, coagulopathy
Chance of bile leak, stent migration

AE, adverse event; EBD, endoscopic transpapillary biliary drainage; ERCP, endoscopic retrograde cholangiopancreatography; EUS-BD, endoscopic ultrasound-guided biliary drainage; IHBD, intrahepatic bile duct; PTBD, percutaneous transhepatic biliary drainage; QOL, quality of life.

  • 1. Moon JH, Rerknimitr R, Kogure H, Nakai Y, Isayama H. Topic controversies in the endoscopic management of malignant hilar strictures using metal stent: side-by-side versus stent-in-stent techniques. J Hepatobiliary Pancreat Sci 2015;22:650–656.ArticlePubMed
  • 2. Nakai Y, Isayama H, Yamamoto N, et al. Indications for endoscopic ultrasonography (EUS)-guided biliary intervention: does EUS always come after failed endoscopic retrograde cholangiopancreatography? Dig Endosc 2017;29:218–225.ArticlePubMed
  • 3. Minaga K, Kitano M. Recent advances in endoscopic ultrasound-guided biliary drainage. Dig Endosc 2018;30:38–47.ArticlePubMed
  • 4. Nakai Y, Isayama H, Matsubara S, Koike K. Conversion of transpapillary drainage to endoscopic ultrasound-guided hepaticogastrostomy and gallbladder drainage in a case of malignant biliary obstruction with recurrent cholangitis and cholecystitis (with videos). Endosc Ultrasound 2017;6:205–207.ArticlePubMedPMC
  • 5. Moole H, Dharmapuri S, Duvvuri A, et al. Endoscopic versus percutaneous biliary drainage in palliation of advanced malignant hilar obstruction: a meta-analysis and systematic review. Can J Gastroenterol Hepatol 2016;2016:4726078.ArticlePubMedPMCPDF
  • 6. Sangchan A, Kongkasame W, Pugkhem A, Jenwitheesuk K, Mairiang P. Efficacy of metal and plastic stents in unresectable complex hilar cholangiocarcinoma: a randomized controlled trial. Gastrointest Endosc 2012;76:93–99.ArticlePubMed
  • 7. Mukai T, Yasuda I, Nakashima M, et al. Metallic stents are more efficacious than plastic stents in unresectable malignant hilar biliary strictures: a randomized controlled trial. J Hepatobiliary Pancreat Sci 2013;20:214–222.ArticlePubMed
  • 8. De Palma GD, Galloro G, Siciliano S, Iovino P, Catanzano C. Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study. Gastrointest Endosc 2001;53:547–553.ArticlePubMed
  • 9. Yasuda I, Mukai T, Moriwaki H. Unilateral versus bilateral endoscopic biliary stenting for malignant hilar biliary strictures. Dig Endosc 2013;25 Suppl 2:81–85.ArticlePubMed
  • 10. Takahashi E, Fukasawa M, Sato T, et al. Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry. World J Gastroenterol 2015;21:4946–4953.ArticlePubMedPMC
  • 11. Vienne A, Hobeika E, Gouya H, et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endosc 2010;72:728–735.ArticlePubMed
  • 12. Lee TH, Kim TH, Moon JH, et al. Bilateral versus unilateral placement of metal stents for inoperable high-grade malignant hilar biliary strictures: a multicenter, prospective, randomized study (with video). Gastrointest Endosc 2017;86:817–827.ArticlePubMedPMC
  • 13. Lee TH, Moon JH, Kim JH, et al. Primary and revision efficacy of crosswired metallic stents for endoscopic bilateral stent-in-stent placement in malignant hilar biliary strictures. Endoscopy 2013;45:106–113.ArticlePubMedPDF
  • 14. Kogure H, Isayama H, Nakai Y, et al. High single-session success rate of endoscopic bilateral stent-in-stent placement with modified large cell Niti-S stents for malignant hilar biliary obstruction. Dig Endosc 2014;26:93–99.ArticlePubMed
  • 15. Lee TH, Park DH, Lee SS, et al. Technical feasibility and revision efficacy of the sequential deployment of endoscopic bilateral side-by-side metal stents for malignant hilar biliary strictures: a multicenter prospective study. Dig Dis Sci 2013;58:547–555.ArticlePubMedPDF
  • 16. Lee TH, Moon JH, Choi HJ, et al. Third metal stent for revision of malignant hilar biliary strictures. Endoscopy 2016;48:1129–1133.ArticlePubMedPDF
  • 17. Nakai Y, Isayama H, Yamamoto N, et al. Safety and effectiveness of a long, partially covered metal stent for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction. Endoscopy 2016;48:1125–1128.ArticlePubMedPDF
  • 18. Ogura T, Sano T, Onda S, et al. Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips. Endoscopy 2015;47:72–75.ArticlePubMedPDF
  • 19. Park SJ, Choi JH, Park DH, et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc 2013;78:374–380.ArticlePubMedPMC
  • 20. Mukai S, Itoi T, Tsuchiya T, Tanaka R, Tonozuka R. EUS-guided right hepatic bile duct drainage in complicated hilar stricture. Gastrointest Endosc 2017;85:256–257.ArticlePubMed
  • 21. Park DH. Endoscopic ultrasound-guided biliary drainage of hilar biliary obstruction. J Hepatobiliary Pancreat Sci 2015;22:664–668.ArticlePubMed
  • 22. Bories E, Pesenti C, Caillol F, Lopes C, Giovannini M. Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study. Endoscopy 2007;39:287–291.ArticlePubMed
  • 23. Ogura T, Masuda D, Imoto A, Umegaki E, Higuchi K. EUS-guided hepaticogastrostomy for hepatic hilar obstruction. Endoscopy 2014;46 Suppl 1 UCTN:E32–E33.ArticlePubMedPDF
  • 24. Prachayakul V, Aswakul P. Endoscopic ultrasound-guided biliary drainage: bilateral systems drainage via left duct approach. World J Gastroenterol 2015;21:10045–10048.ArticlePubMedPMC
  • 25. Moryoussef F, Sportes A, Leblanc S, Bachet JB, Chaussade S, Prat F. Is EUS-guided drainage a suitable alternative technique in case of proximal biliary obstruction? Therap Adv Gastroenterol 2017;10:537–544.ArticlePubMedPMC
  • 26. Park DH, Song TJ, Eum J, et al. EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos). Gastrointest Endosc 2010;71:413–419.ArticlePubMedPMC
  • 27. Minaga K, Takenaka M, Kitano M, et al. Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention. Surg Endosc 2017;31:4764–4772.ArticlePubMedPMCPDF
  • 28. Ogura T, Onda S, Takagi W, et al. Clinical utility of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention procedure for high-grade hilar stricture. J Gastroenterol Hepatol 2017;32:163–168.ArticlePubMedPMC
  • 29. Kanno Y, Ito K, Koshita S, et al. EUS-guided biliary drainage for malignant perihilar biliary strictures after further transpapillary intervention has been judged to be impossible or ineffective. Intern Med 2017;56:3145–3151.ArticlePubMedPMC
  • 30. Wang K, Zhu J, Xing L, Wang Y, Jin Z, Li Z. Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review. Gastrointest Endosc 2016;83:1218–1227.ArticlePubMedPMC
  • 31. Dhir V, Artifon EL, Gupta K, et al. Multicenter study on endoscopic ultrasound-guided expandable biliary metal stent placement: choice of access route, direction of stent insertion, and drainage route. Dig Endosc 2014;26:430–435.ArticlePubMedPMC
  • 32. Paik WH, Lee NK, Nakai Y, et al. Conversion of external percutaneous transhepatic biliary drainage to endoscopic ultrasound-guided hepaticogastrostomy after failed standard internal stenting for malignant biliary obstruction. Endoscopy 2017;49:544–548.ArticlePubMedPDF

Figure & Data

REFERENCES

    Citations

    Citations to this article as recorded by  
    • Novel approach to bilateral biliary drainage: EUS-guided hepaticoduodenodenostomy plus hepaticogastrostomy in malignant hilar biliary obstruction
      Susumu Hijioka, Yoshikuni Nagashio, Yuta Maruki, Shota Harai, Daiki Agarie, Daiki Yamashige, Kohei Okamoto, Shin Yagi, Soma Fukuda, Yasuhiro Komori, Masaru Kuwada, Yutaka Saito, Takuji Okusaka
      Endoscopy International Open.2025;[Epub]     CrossRef
    • Endoscopic treatment of unresectable perihilar cholangiocarcinoma: beyond biliary drainage
      Di Zhang, Tianci Shen, Feng Gao, Yong Sun, Zihao Dai, Haifeng Luo, Yanan Sun, Zhuo Yang, Jiangning Gu
      Therapeutic Advances in Gastroenterology.2025;[Epub]     CrossRef
    • Retrospective comparative study of new slim‐delivery and conventional large‐cell stents for stent‐in‐stent methods for hilar malignant biliary obstruction
      Kazunaga Ishigaki, Rintaro Fukuda, Yousuke Nakai, Go Endo, Kohei Kurihara, Kota Ishida, Shuichi Tange, Shinya Takaoka, Yurie Tokito, Yukari Suzuki, Hiroki Oyama, Sachiko Kanai, Tatsunori Suzuki, Yukiko Ito, Tatsuya Sato, Ryunosuke Hakuta, Kei Saito, Tomot
      Digestive Endoscopy.2024; 36(3): 360.     CrossRef
    • ERCP for the initial management of malignant biliary obstruction – real world data on 596 procedures
      I. M. Mikalsen, S. Breder, A. W. Medhus, T. Folseraas, L. Aabakken, K. V. Ånonsen
      Scandinavian Journal of Gastroenterology.2024; 59(3): 369.     CrossRef
    • A Novel Method of Calculating the Drained Liver Volume Using a 3D Volume Analyzer for Biliary Drainage of Unresectable Malignant Hilar Biliary Obstruction
      Naoto Imagawa, Mitsuharu Fukasawa, Shinichi Takano, Satoshi Kawakami, Yoshimitsu Fukasawa, Hiroyuki Hasegawa, Natsuhiko Kuratomi, Shota Harai, Naruki Shimamura, Dai Yoshimura, Shoji Kobayashi, Takashi Yoshida, Mitsuaki Sato, Yuichiro Suzuki, Nobuyuki Enom
      Digestive Diseases and Sciences.2024; 69(3): 969.     CrossRef
    • Safety of endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction and ascites
      Tsukasa Yasuda, Kazuo Hara, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Yasuhiro Kuraishi, Takafumi Yanaidani, Sho Ishikawa, Masanori Yamada, Toshitaka Fukui
      Clinical Endoscopy.2024; 57(2): 246.     CrossRef
    • A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure
      Hidenobu Hara, Susumu Hijioka, Yoshikuni Nagashio, Yuta Maruki, Mark Chatto, Yutaka Saito, Takuji Okusaka
      VideoGIE.2024; 9(6): 286.     CrossRef
    • Comparison of stent patency between EUS-guided hepaticogastrostomy with bridging and endoscopic transpapillary biliary drainage for hilar obstruction
      Kotaro Takeshita, Susumu Hijioka, Yoshikuni Nagashio, Yuta Maruki, Akihiro Ohba, Yuki Kawasaki, Tetsuro Takasaki, Shin Yagi, Daiki Agarie, Hidenobu Hara, Yuya Hagiwara, Daiki Yamashige, Kohei Okamoto, Soma Fukuda, Masaru Kuwada, Mark Chatto, Shunsuke Kond
      Endoscopy International Open.2024; 12(07): E875.     CrossRef
    • Defining failure of endoluminal biliary drainage in the era of endoscopic ultrasound and lumen apposing metal stents
      Faisal S Ali, Sushovan Guha
      World Journal of Gastroenterology.2024; 30(29): 3534.     CrossRef
    • Three-year evaluation of a novel, nonfluoroscopic, all-artificial model for EUS-guided biliary drainage training for the impact to practice: A prospective observational study (with videos)
      Tanyaporn Chantarojanasiri, Aroon Siripun, Pradermchai Kongkam, Nonthalee Pausawasdi, Thawee Ratanachu-ek
      Endoscopic Ultrasound.2023; 12(1): 96.     CrossRef
    • Endoscopic management of benign and malignant hilar stricture
      Marcella Pimpinelli, Michael Makar, Michel Kahaleh
      Digestive Endoscopy.2023; 35(4): 443.     CrossRef
    • Endoscopic and Endosonographic Palliation for Triple Obstruction Caused by Recurrent Gallbladder Cancer: A Case Report
      Young Rong Kim, Chi Hyuk Oh, Min Jae Yang
      The Korean Journal of Pancreas and Biliary Tract.2023; 28(1): 19.     CrossRef
    • Unpredictable Event during EUS-Guided Hepaticojejunostomy
      Abdullatif SİRİN, Mehmet ÇETİN, Salih TOKMAK
      Düzce Tıp Fakültesi Dergisi.2023; 25(1): 89.     CrossRef
    • Optimal endoscopic drainage strategy for unresectable malignant hilar biliary obstruction
      Itaru Naitoh, Tadahisa Inoue
      Clinical Endoscopy.2023; 56(2): 135.     CrossRef
    • Role of radiofrequency ablation in advanced malignant hilar biliary obstruction
      Mamoru Takenaka, Tae Hoon Lee
      Clinical Endoscopy.2023; 56(2): 155.     CrossRef
    • Preoperative endoscopic ultrasound-guided biliary drainage for primary drainage in obstructive jaundice
      Shuntaro Mukai, Takao Itoi
      Expert Review of Gastroenterology & Hepatology.2023; 17(12): 1197.     CrossRef
    • Use of endoscopic ultrasound‐guided biliary drainage as a rescue of re‐intervention after the placement of multiple metallic stents for malignant hilar biliary obstruction
      Hidetoshi Kitamura, Susumu Hijioka, Yoshikuni Nagashio, Shunsuke Sugawara, Satoshi Nara, Miyuki Sone, Minoru Esaki, Yasuaki Arai, Takuji Okusaka, Atsushi Nakajima
      Journal of Hepato-Biliary-Pancreatic Sciences.2022; 29(3): 404.     CrossRef
    • Practical Tips for Safe and Successful Endoscopic Ultrasound-Guided Hepaticogastrostomy: A State-of-the-Art Technical Review
      Saburo Matsubara, Keito Nakagawa, Kentaro Suda, Takeshi Otsuka, Masashi Oka, Sumiko Nagoshi
      Journal of Clinical Medicine.2022; 11(6): 1591.     CrossRef
    • Role of ERCP in Malignant Hilar Biliary Obstruction
      Tae Hoon Lee, Jong Ho Moon, Sherman Stuart
      Gastrointestinal Endoscopy Clinics of North America.2022; 32(3): 427.     CrossRef
    • Endoscopic management of perihilar cholangiocarcinoma
      Hiroki Kawashima, Eizaburo Ohno, Takuya Ishikawa, Yasuyuki Mizutani, Tadashi Iida, Takeshi Yamamura, Naomi Kakushima, Kazuhiro Furukawa, Masanao Nakamura
      Digestive Endoscopy.2022; 34(6): 1147.     CrossRef
    • Combination of ERCP with endoscopic ultrasound-guided hepaticogastrostomy and hepaticoduodenostomy for biliary drainage in malignant hilar biliary obstruction
      Haruka Toyonaga, Tsuyoshi Hayashi, Toshifumi Kin, Kazuki Hama, Kosuke Iwano, Risa Nakamura, Akio Katanuma
      Endoscopy.2022; 54(S 02): E912.     CrossRef
    • A case of malignant hilar biliary obstruction after total gastrectomy treated by EUS-HJS + bridging stenting
      Yurie Tokito, Ryunosuke Hakuta, Hirofumi Kogure, Yousuke Nakai, Mitsuhiro Fujishiro
      Progress of Digestive Endoscopy.2022; 100(1): 50.     CrossRef
    • Current endoscopic approaches to biliary strictures
      Tatsuya Sato, Yousuke Nakai, Mitsuhiro Fujishiro
      Current Opinion in Gastroenterology.2022; 38(5): 450.     CrossRef
    • Endoscopic ultrasound-guided biliary drainage in malignant hilar obstruction
      Se Woo Park
      International Journal of Gastrointestinal Intervention.2022; 11(3): 105.     CrossRef
    • Comparative Study on Nosocomial Biliary Tract Infection Rate Between Biliary Stent Loaded with Radioactive 125I Seeds and Conventional Biliary Stent in the Treatment of Distal Malignant Biliary Obstruction
      Jianli An, Yanchao Dong, Hongtao Niu, Yanguo Li, Xiaoyu Han, Zibo Zou, Jingpeng Wu, Ye Tian, Zhuo Chen
      Surgical Laparoscopy, Endoscopy & Percutaneous Techniques.2022; 32(6): 724.     CrossRef
    • ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: a multicenter observational open-label study
      Pradermchai Kongkam, Theerapat Orprayoon, Chaloemphon Boonmee, Passakorn Sodarat, Orathai Seabmuangsai, Chatchawan Wachiramatharuch, Yutthaya Auan-Klin, Khanh Cong Pham, Abbas Ali Tasneem, Stephen J. Kerr, Rommel Romano, Sureeporn Jangsirikul, Wiriyaporn
      Endoscopy.2021; 53(01): 55.     CrossRef
    • Feasibility of EUS-guided hepaticogastrostomy for inoperable malignant hilar biliary strictures
      Jérôme Winkler, Fabrice Caillol, Jean-Philippe Ratone, Erwan Bories, Christian Pesenti, Marc Giovannini
      Endoscopic Ultrasound.2021; 10(1): 51.     CrossRef
    • Combined ERCP and transhepatic endoscopic ultrasound-guided stent placement for biliary drainage in malignant hilar obstruction: not too good to be true
      Manuel Perez-Miranda
      Endoscopy.2021; 53(01): 63.     CrossRef
    • Extrahepatic cholangiocarcinoma: Current status of endoscopic approach and additional therapies
      Alina Ioana Tantau, Alina Mandrutiu, Anamaria Pop, Roxana Delia Zaharie, Dana Crisan, Carmen Monica Preda, Marcel Tantau, Voicu Mercea
      World Journal of Hepatology.2021; 13(2): 166.     CrossRef
    • Efficacy of lumen-apposing metal stents or self-expandable metal stents for endoscopic ultrasound-guided choledochoduodenostomy: a systematic review and meta-analysis
      Arnaldo Amato, Emanuele Sinagra, Ciro Celsa, Marco Enea, Andrea Buda, Filippo Vieceli, Lucia Scaramella, Paul Belletrutti, Alessandro Fugazza, Calogero Cammà, Franco Radaelli, Alessandro Repici, Andrea Anderloni
      Endoscopy.2021; 53(10): 1037.     CrossRef
    • What You Need to Know Before Performing Endoscopic Ultrasound-guided Hepaticogastrostomy
      Tanyaporn Chantarojanasiri, Thawee Ratanachu-Ek, Nonthalee Pausawasdi
      Clinical Endoscopy.2021; 54(3): 301.     CrossRef
    • EUS-guided biliary drainage for malignant hilar biliary obstruction: A concise review
      Sridhar Sundaram, Vinay Dhir
      Endoscopic Ultrasound.2021; 10(3): 154.     CrossRef
    • Proper management of inoperable malignant hilar biliary obstruction: Endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, or percutaneous approach?
      Tae Hoon Lee
      International Journal of Gastrointestinal Intervention.2021; 10(3): 120.     CrossRef
    • A Recent Update on Endoscopic Drainage of Advanced Malignant Hilar Obstruction
      Tae Hoon Lee, Jong Ho Moon, Sang-Heum Park
      The Korean Journal of Gastroenterology.2021; 78(2): 94.     CrossRef
    • Endoscopic Biliary Drainage for Hilar Obstruction: Further Evidence But Still A Long Way To Go
      Yousuke Nakai
      Clinical Endoscopy.2021; 54(5): 629.     CrossRef
    • EUS-guided antegrade metallic stent placement using the stent-in-stent method with a 6-Fr novel slim delivery system in a patient with malignant hilar biliary obstruction
      Shigeyuki Suenaga, Seiji Kaino, Takanori Tsuyama, Yuko Fujimoto, Shogo Amano, Toshiyuki Uekitani, Isao Sakaida
      Endoscopic Ultrasound.2021; 10(5): 387.     CrossRef
    • Retrospective Comparative Study of Side-by-Side and Stent-in-Stent Metal Stent Placement for Hilar Malignant Biliary Obstruction
      Kazunaga Ishigaki, Tsuyoshi Hamada, Yousuke Nakai, Hiroyuki Isayama, Tatsuya Sato, Ryunosuke Hakuta, Kei Saito, Tomotaka Saito, Naminatsu Takahara, Suguru Mizuno, Hirofumi Kogure, Yukiko Ito, Hiroshi Yagioka, Saburo Matsubara, Dai Akiyama, Dai Mohri, Mino
      Digestive Diseases and Sciences.2020; 65(12): 3710.     CrossRef
    • Radiologic Assessment for Endoscopic US-guided Biliary Drainage
      Shunsuke Sugawara, Miyuki Sone, Shinichi Morita, Susumu Hijioka, Yasunari Sakamoto, Masahiko Kusumoto, Yasuaki Arai
      RadioGraphics.2020; 40(3): 667.     CrossRef
    • Endoscopic ultrasound‐guided bilateral biliary drainage through the mesh of the metal stents using a balloon occlusion method
      Kazunari Nakahara, Ryo Morita, Fumio Itoh
      Digestive Endoscopy.2020;[Epub]     CrossRef
    • Simultaneous endoscopic ultrasound-guided hepaticogastrostomy and bridging stenting with partial stent-in-stent method
      Kosuke Maehara, Susumu Hijioka, Yoshikuni Nagashio, Akihiro Ohba, Yuya Kanai, Takuji Okusaka, Yutaka Saito
      Endoscopy.2020; 52(10): E381.     CrossRef
    • Efficacy and safety of EUS biliary drainage in malignant distal and hilar biliary obstruction: A comprehensive review of literature and algorithm
      Stanley Khoo, NhanDuc Tri Do, Pradermchai Kongkam
      Endoscopic Ultrasound.2020; 9(6): 369.     CrossRef
    • Acute biliary interventions
      T.C. See
      Clinical Radiology.2019;[Epub]     CrossRef
    • Endoscopic ultrasound-guided biliary drainage: A change in paradigm?
      En-Ling Leung Ki EL, Bertrand Napoleon
      World Journal of Gastrointestinal Endoscopy.2019; 11(5): 345.     CrossRef
    • Drainage of the right liver using EUS guidance
      Fabrice Caillol, Mathieu Rouy, Christian Pesenti, Jean-Philippe Ratone, Marc Giovannini
      Endoscopic Ultrasound.2019; 8(7): 50.     CrossRef

    • PubReader PubReader
    • ePub LinkePub Link
    • Cite
      CITE
      export Copy Download
      Close
      Download Citation
      Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.
      Format:
      • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
      • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
      Include:
      • Citation for the content below
      Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction
      Clin Endosc. 2019;52(3):220-225.   Published online November 29, 2018
      DOI: https://doi.org/10.5946/ce.2018.094
      Close
    • XML DownloadXML Download
    Figure
    • 0
    • 1
    • 2
    Related articles
    Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction
    Image Image Image
    Fig. 1. Techniques of bilateral endoscopic ultrasound-guided biliary drainage. (A) Bridging method. (B) Endoscopic ultrasound-guided hepaticoduodenostomy. (C) Combined endoscopic ultrasound-guided hepaticogastrostomy and transpapillary stenting.
    Fig. 2. Bridging method. (A) Endoscopic ultrasound-guided hepaticogastrostomy was performed during the first session. (B) A bridging stent was placed during the second session.
    Fig. 3. Combined endoscopic ultrasound-guided hepaticogastrostomy and transpapillary stenting. (A) Endoscopic ultrasound-guided hepaticogastrostomy was performed during the first session. (B) Transpapillary multiple stent-in-stent placement was performed during the second session.

    Fig. 1.

    Fig. 2.

    Fig. 3.

    Endoscopic Ultrasound-Guided Biliary Drainage for Unresectable Hilar Malignant Biliary Obstruction
    Indications
     Failed ERCP
     Surgically altered anatomy i.e., Roux-en-Y reconstruction
     Failed re-intervention for transpapillary stent occlusion
    Contraindications
     Severe coagulopathy
     Massive ascites
     Intervening vessels including collateral vessels
     Unstable conditions unfit for endoscopic procedures
    Study n Initial/rescue Stent Drainage method Technical success Clinical success Adverse events
    Bories et al. (2007) [22] 4 Initial PS HGS 4 4 1 stent clogging
    Ogura et al. (2014) [23] 1 Initial UMS+CMS Bridging 1 N/A N/A
    Ogura et al. (2015) [18] 11 Initial/Rescue UMS+CMS 4 HDS, 7 Bridging 11 N/A 0
    Prachayakul et al. (2015) [24] 1 Initial UMS+CMS Bridging 1 1 0
    Moryoussef et al. (2017) [25] 18 Initial UMS+CMS 14 HGS, 3 Bridging 17 13 3
    Park et al. (2010) [26] 3 Rescue CMS HGS 3 3 0
    Park et al. (2013) [19] 2 Rescue CMS HDS 2 2 0
    Minaga et al. (2017) [27] 30 Rescue CMS or PS 28 HGS, 2 HDS 29 22 3 bile peritonitis
    Ogura et al. (2017) [28] 10 Rescue CMS 8 HGS, 2 HDS 10 9 0
    Kanno et al. (2017) [29] 7 Rescue CMS HGS 7 4 0
    Mukai et al. (2017) [20] 1 Rescue PS HDS 1 N/A 0
    Overall 88 98% (86/88) 77% (58/75) 8% (7/87)
    EUS-BD EBD PTBD
    Advantage A single step internal drainage Long term data available High technical success rate
    Simplicity at the hilum: possible longer patency Possible tube rinse for clogging
    Disadvantage No long term data Technical difficulty for multiple stenting Impaired QOL
    Special technique necessary for right IHBD approach Complexity at the hilum High AE rate and re-intervention rate
    Contraindications: ascites, coagulopathy Chance of Post-ERCP pancreatitis Contraindications: ascites, coagulopathy
    Chance of bile leak, stent migration
    Table 1. Current Indications and Contraindications of Endoscopic Ultrasound-Guided Biliary Drainage for Hilar Malignant Biliary Obstruction

    ERCP, endoscopic retrograde cholangiopancreatography.

    Table 2. Data on Endoscopic Ultrasound-Guided Biliary Drainage for Hilar Malignant Biliary Obstruction

    CMS, covered metal stent; HDS, hepaticoduodenostomy; HGS, hepaticogastrostomy; N/A, not available; PS, plastic stent; UMS, uncovered metal stent.

    Table 3. Advantages and Disadvantages of EUS-BD

    AE, adverse event; EBD, endoscopic transpapillary biliary drainage; ERCP, endoscopic retrograde cholangiopancreatography; EUS-BD, endoscopic ultrasound-guided biliary drainage; IHBD, intrahepatic bile duct; PTBD, percutaneous transhepatic biliary drainage; QOL, quality of life.

    Table 1.

    Table 2.

    Table 3.

    Clin Endosc : Clinical Endoscopy Twitter Facebook
    © Korean Society of Gastrointestinal Endoscopy.
    Close layer
    TOP