Biliary drainage in patients with altered anatomy: Literature review of different endoscopic approaches

Table 1 Different types of surgical altered anatomy and the corresponding endoscopic ultrasound-guided biliary drainage procedures

Surgically altered anatomy	EUS biliary drainage procedure
Sleeve gastrectomy	EUS-CD, rendezvous, EUS HGS, antegrade drainage
Billroth-I gastrectomy	EUS-CD, rendezvous, EUS-HGS, antegrade drainage
Billroth-II gastrectomy	EUS-HGS, rendezvous, antegrade drainage
Roux-en-Y gastric bypass	EUS-HGS, antegrade drainage, EDGE
Whipple’s procedure	EUS-HGS, rendezvous, antegrade drainage
Hepaticojejunostomy	EUS HGS, rendezvous, antegrade drainage

EUS: Endoscopic ultrasound; EDGE: Endoscopic ultrasound directed transgastric endoscopic retrograde cholangiopancreatography; EUS-HGS: Endoscopic ultrasound-guided hepatogastrostomy; EUS-CD: Endoscopic ultrasound-guided choledochoduodenostomy.

Table 2 Comparative outcomes table between entero-endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and percutaneous transhepatic biliary drainage

Modality	Billroth II gastrectomy	RYGB	Post-Whipple and hepaticojejunostomy
Enteroscopy-assisted ERCP	Technical success: High, up to 97%. Clinical success: High. AE rates: Low. Procedural time: Shorter than other SAA, often using forward-viewing scopes	Technical success: 82.2%. Clinical success: Lower, 65.1% (intervention). AE rates: 5.7% (overall). Rare complications like hepatic subcapsular hematoma. Procedural time: Long and technically demanding due to long, tortuous limb	Technical success: 70%-90%. Clinical success: 88% (biliary). AE rates: Up to 11% (biliary), generally mild. Procedural time: Long and complex
EUS-guided biliary drainage	Technical success: Very high, 89.4% (for all EUS-BD methods). Clinical success: Very high, 96.2%. AE rates: 6%-20%. Procedural time: More efficient than failed ERCP attempts	Technical success: > 85%-90%, with EDGE reaching > 97.9%. Clinical success: > 80%. AE rates: 13.1% (for EDGE). Procedural time: Shorter and more efficient than enteroscopy, particularly for long-limb reconstructions	Technical success: 80%-90%. Clinical success: 85%-92%. AE rates: 10%-20%. Procedural time: More efficient as a rescue method
PTBD	Technical success: 90%-97% clinical success: High AE rates: < 15% (long term issues and reinterventions) procedural time: 1-2 hours

Technical success: Refers to achieving the technical goal (e.g., stent placement); clinical success: Refers to the resolution of the patient's symptoms (e.g., reduction of cholangitis); adverse event rate: The percentage of reported complications. The overall rates are summaries from the cited literature and can vary significantly depending on the specific study. ERCP: Endoscopic retrograde cholangiopancreatography; AE: Adverse event; SAA: Surgically altered anatomy; EUS: Endoscopic ultrasound; EUS-BD: Endoscopic ultrasound-guided biliary drainage; EDGE: Endoscopic ultrasound directed transgastric endoscopic retrograde cholangiopancreatography; PTBD: Percutaneous transhepatic biliary drainage; RYGB: Roux-en-Y gastric bypass.

Table 3 Biliary drainage strategies in patients with surgically altered anatomy

Type of anatomy	Preferred approach	Indicated instruments	Alternative approaches
Billroth II gastrectomy	ERCP with forward-viewing scope	Operative gastroscope, pediatric colonoscope	EUS-rendezvous
Roux-en-Y gastric bypass	EUS-BD (EDGE)	EUS endoscope, LAMS stent	PTBD, surgical drainage, LA-ERCP
Post-Whipple and bilioenteric anastomoses	DAE-ERCP	SBE, DBE	EUS-rendezvous, EUS-BD, PTBD

ERCP: Endoscopic retrograde cholangiopancreatography; EUS-BD: Endoscopic ultrasound-guided biliary drainage; EDGE: Endoscopic ultrasound directed transgastric endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; PTBD: Percutaneous transhepatic biliary drainage; LAMS: Lumen-apposing metal stent; LA-ERCP: Laparoscopic-assisted endoscopic retrograde cholangiopancreatography; DAE: Device-assisted enteroscopy; SBE: Single-balloon enteroscopy; DBE: Double-balloon enteroscopy.