EUS-guided biliary drainage with antegrade transpapillary placement of a metal biliary stent

EUS-guided biliary drainage (EUS-BD) is a minimally invasive technique that provides biliary drainage in patients with malignant biliary obstruction in whom endoscopic retrograde cholangiography (ERC) is not feasible. Intrahepatic or extrahepatic biliary access is obtained, after which transluminal or transpapillary drainage is performed with stent placement. Transpapillary stents can be placed in a retrograde fashion by using the rendezvous technique in which endoscope exchange is required. A transpapillary stent also can be placed in an antegrade fashion. We present two cases: (1) A 58-year-old man with a biliary obstruction caused by a 6-cm mass (adenocarcinoma) in the head of the pancreas underwent ERC. Deep biliary access could not be obtained because of a long distal common bile duct stricture. (2) A 40-year-old man with prior Whipple’s surgery for pancreatic adenocarcinoma had recurrence at the hepatojejunostomy. ERC failed because of difficulties with intubation of the afferent limb. In both cases, EUS was performed, and dilated intrahepatic ducts were identified and punctured with a 19-gauge EUS needle, via a transgastric approach. Cholangiography demonstrated a dilated proximal biliary tree with a distal biliary stricture. A wire was advanced through the needle and toward the papilla and/or hepatojejunostomy. The stricture was dilated with a biliary balloon dilator. The duodenal and/or jejunal lumen was opacified with contrast material to direct stent placement. An uncovered self-expandable metal biliary stent was deployed across the stricture and across the papilla and/or hepatojejunostomy in an antegrade fashion. EUS-guided biliary drainage with antegrade transpapillary stent placement achieved efficient biliary drainage and avoided the need for endoscope exchange (Fig. 1; Video 1, available online at www.giejournal.org).