Endoscopic ultrasound-guided biliary drainage for biliary obstruction

Evidence-based recommendations on endoscopic ultrasound-guided biliary drainage for biliary obstruction. This involves passing a thin tube (called an endoscope) with an ultrasound probe at the tip through the mouth and into the stomach or small intestine. The blockage is located using sound waves and punctured. A short, wire mesh tube that acts like a scaffold (called a stent) is then inserted into the blocked duct. This allows bile to drain into the gut.

# Recommendations
Evidence on the safety and efficacy of endoscopic ultrasound-guided biliary drainage (EUSBD) for biliary obstruction caused by distal malignant disease is adequate to support using this procedure. This is provided that standard arrangements are in place for clinical governance, consent and audit. Find out what standard arrangements mean on the NICE interventional procedures guidance page.
Evidence on the safety and efficacy of EUSBD for biliary obstruction caused by malignant hilar or benign disease is inadequate in quality and quantity. So, this procedure should be used only in research. Find out what only in research means on the NICE interventional procedures guidance page.
Further research should report details of patient selection, where the obstruction is, and whether this procedure has been done after failed endoscopic retrograde cholangiopancreatography.
Patient selection should be done by a multidisciplinary team or, in an emergency, only after agreement with an experienced hepatobiliary team.
This procedure should only be done in specialised centres by a clinician with specific training and experience in the procedure.# The condition, current treatments and procedure

# The condition
Biliary obstruction involves blockage of any duct that carries bile from the liver to the gallbladder or from the gallbladder to the small intestine. It may have benign or malignant causes, and can lead to symptoms including jaundice, nausea and abdominal pain, itching, pale stools and dark urine.

# Current treatments
Current standard management of biliary obstruction usually includes stenting using endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD). For malignant obstruction, treatment may also include chemotherapy, biological therapy, photodynamic therapy and radiofrequency ablation.

# The procedure
Endoscopic ultrasound-guided biliary drainage (EUSBD) is an alternative procedure when ERCP is not possible; ERCP fails in a small proportion of people because of the nature of the obstruction or their anatomy (which may be altered because of disease progression or previous surgery). EUSBD 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.
EUSBD 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 biliary drainage into the stomach or small intestine. Stent delivery systems may also be used to do EUSBD without needle puncture, dilation or insertion of a guidewire.
EUSBD can be done using several different techniques and stents can be deployed through multiple access routes. The 2 most common techniques, endoscopic ultrasound-guided choledochoduodenostomy (EUSCDS) and endoscopic ultrasound-guided hepaticogastrostomy (EUSHGS), both use a transluminal approach. In EUSCDS, the extrahepatic bile duct is punctured, and the stent is deployed via the duodenal bulb. In EUSHGS, the left hepatic duct is punctured, and the stent is deployed via the stomach.
Stents may also be deployed using a transpapillary approach in which the guidewire is passed into the duodenum. In endoscopic ultrasound-guided antegrade stenting (EUSAGS), the stent is placed across the biliary obstruction. In the endoscopic ultrasound-guided rendezvous technique (EUSRV), 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 depends on the cause of the biliary obstruction and the anatomy of the person having the procedure.