Post written by Todd H. Baron, MD, from the Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. 

This study focused on transhepatic biliary drainage using endoscopic ultrasound for management of benign and malignant biliary obstruction.

Although EUS-guided hepaticogastrostomy was first described nearly 20 years ago, almost all series have originated outside the United States and for patients with malignant biliary obstruction. In these series, stents used for transhepatic drainage have not been traditional FDA-approved stents.

We felt it was important to (1) introduce nomenclature of EUS-guided transhepatic biliary drainage to encompass passage from any lumen of the upper gastrointestinal tract (esophagus, stomach, duodenum, jejunum), (2) demonstrate utility for many causes of benign and malignant biliary obstruction, and (3) demonstrate outcomes using available FDA-approved devices. 

We found that when performed by an experienced therapeutic endoscopist, EUS-guided transhepatic biliary drainage is achieved with an extremely high success rate. The adverse event rate is modest. Need for reintervention is low when performed for palliation of malignant biliary obstruction, but as expected it is higher for patients with hilar malignancy compared to distal biliary obstruction. Further studies are needed to determine the learning curve for other endoscopists.    

Although we describe our technical approach to performing EUS-guided transhepatic biliary drainage, there are many technical nuances to successfully completing the procedure that we did not cover. Teaching these skills to advanced endoscopists and trainees will be needed to allow dissemination to a larger audience.

A, Echoendoscopic image of a dilated left intrahepatic system in a patient with occluded, previously placed distal bile duct stent. B, Access of the dilated biliary system with a 19-gauge needle. C, Dilation of the tract with biliary dilation balloon. D, Fluoroscopic image of initial contrast injection through a 19-gauge needle into the left intrahepatic system after needle puncture. E, Fluoroscopic image of balloon dilation of the hepaticogastrostomy tract. F, Fluoroscopic image of metal stent deployment in the hepaticogastrostomy tract.

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