Initial clinical experience of a steerable access device for EUS-guided biliary drainage

  • Marvin Ryou
    Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
    Search for articles by this author
  • Petros C. Benias
    Division of Gastroenterology, Northwell Health, North Shore University Hospital, Manhasset, New York, USA
    Search for articles by this author
  • Vivek Kumbhari
    Reprint requests: Vivek Kumbhari, MD, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Sheikh Zayed Building, 1800 Orleans St, Suite 7125G, Baltimore, MD 21287.
    Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
    Search for articles by this author
Published:August 10, 2019DOI:

      Background and Aims

      EUS-guided biliary drainage (EUS-BD) has been used as a rescue procedure after failed endoscopic retrograde cholangiography (ERC), and there is growing interest in EUS-BD as a primary therapy for distal malignant biliary obstruction. After EUS-guided needle puncture of an obstructed bile duct, directional control of wire advancement remains an area of need, potentially addressed by a new steerable EUS access system. The aim of this study was to evaluate the safety and efficacy of this novel steerable access system in patients undergoing EUS-BD after failed ERC.


      We performed a retrospective study of prospectively acquired data at 3 tertiary academic hospitals. Consecutive patients who had failed ERC followed by EUS-BD using the access device were included. Primary outcomes were safety and technical feasibility (successful completion of EUS-BD). Secondary outcomes were clinical success (75% improvement in liver function tests at 30 days) and device performance.


      Twenty-two consecutive patients underwent EUS-BD between October 10, 2018 and March 3, 2019. Needle puncture and selective wire advancement in the intended direction were both successful in 100% of cases (22/22). Technical success was 95% (21/22). Fifty-nine percent (13) underwent rendezvous, 32% (7) underwent choledochoduodenostomy, and 4.5% (1) underwent hepaticogastrostomy. One patient (4.5%) underwent percutaneous transhepatic cholangiography. There were no cases of wire shearing. The adverse event rate was 4.5% (mild pancreatitis in 1 patient). There was no bile leak, bleeding, or death at 30 days' follow-up.


      This first clinical experience with a steerable access system for EUS-BD suggests it is safe and effective, particularly with regard to controlling direction of wire advancement.


      CDS (choledochoduodenostomy), ERC (endoscopic retrograde cholaniography), EUS-BD (EUS-guided biliary drainage), FDA (U.S. Food and Drug Administration), HGS (hepaticogastrostomy), PTBD (percutaneous transhepatic biliary drainage), RDV (rendezvous)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Sharaiha R.Z.
        • Khan M.A.
        • Kamal F.
        • et al.
        Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis.
        Gastrointest Endosc. 2017; 85: 904-914
        • Khan M.A.
        • Akbar A.
        • Baron T.H.
        • et al.
        Endoscopic ultrasound-guided biliary drainage: a systematic review and meta-analysis.
        Dig Dis Sci. 2016; 61: 684-703
        • Giovannini M.
        • Moutardier V.
        • Pesenti C.
        • et al.
        Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.
        Endoscopy. 2001; 33: 898-900
        • Guo J.
        • Giovannini M.
        • Sahai A.V.
        • et al.
        A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction.
        Endosc Ultrasound. 2018; 7: 356-365
        • Iwashita T.
        • Uemura S.
        • Yoshida K.
        • et al.
        EUS-guided hybrid rendezvous technique as salvage for standard rendezvous with intra-hepatic bile duct approach.
        PLoS One. 2018; 13: e0202445
        • Lopes L.
        • Dinis-Ribeiro M.
        • Rolanda C.
        Early precut fistulotomy for biliary access: time to change the paradigm of “the later, the better”?.
        Gastrointest Endosc. 2014; 80: 634-641
        • Testoni P.A.
        • Mariani A.
        • Aabakken L.
        • et al.
        Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
        Endoscopy. 2016; 48: 657-683
        • Cotton P.B.
        • Eisen G.M.
        • Aabakken L.
        • et al.
        A lexicon for endoscopic adverse events: report of an ASGE workshop.
        Gastrointest Endosc. 2010; 71: 446-454
        • Tsuchiya T.
        • Itoi T.
        • Sofuni A.
        • et al.
        Endoscopic ultrasonography-guided rendezvous technique.
        Dig Endosc. 2016; 28: 96-101
        • Gupta K.
        • Perez-Miranda M.
        • Kahaleh M.
        • et al.
        Endoscopic ultrasound-assisted bile duct access and drainage: multicenter, long-term analysis of approach, outcomes, and complications of a technique in evolution.
        J Clin Gastroenterol. 2014; 48: 80-87
        • Nakai Y.
        • Kogure H.
        • Isayama H.
        • et al.
        Endoscopic ultrasound-guided biliary drainage for benign biliary diseases.
        Clin Endosc. 2019; 52: 212-219
        • Hindryckx P.
        • Degroote H.
        • Tate D.J.
        • et al.
        Endoscopic ultrasound-guided drainage of the biliary system: techniques, indications and future perspectives.
        World J Gastrointest Endosc. 2019; 11: 103-114