• Endoscopic approaches
• Gastrointestinal cancers
• Nausea
• Palliative care
• Vomiting

• advanced inoperable malignancy
• drainage interventional ultrasound
• obstructive jaundice

Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay procedure of choice for management of obstructive biliary disease. While ERCP is widely performed with high success rates, the procedure is not feasible in every patient such as cases of non-accessible papilla. In the setting of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). A variety of different forms of EUS-BD have been described, allowing for both intrahepatic and extrahepatic approaches. Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage, with fewer adverse events when compared to PTBD. Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure. The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists. The aim of our review is to highlight the different EUS-guided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.

• Endoscopic ultrasound-guided biliary drainage
• Endoscopic ultrasound-guided rendezvous
• Endoscopic ultrasound-guided choledochoduodenostomy
• Endoscopic ultrasound-guided hepaticogastrostomy
• Endoscopic ultrasound-guided gallbladder drainage
• Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography

Pancreatic cancer is a lethal cancer with an increasing incidence. Despite improvements in chemotherapy, patients with pancreatic cancer continue to face poor prognoses. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is the primary method for obtaining tissue samples of pancreatic cancer. Due to advancements in next-generation sequencing (NGS) technologies, multiple parallel sequencing can be applied to EUS-TA samples. Genomic biomarkers for therapeutic stratification in pancreatic cancer are still lacking, however, NGS can unveil potential predictive genomic biomarkers of treatment response. Thus, the importance of NGS using EUS-TA samples is becoming recognized. In this review, we discuss the recent advances in EUS-TA application for NGS of pancreatic cancer.

• biomarker
• endoscopic ultrasound-guided fine needle aspiration
• endoscopic ultrasound-guided fine needle biopsy
• endoscopic ultrasound-guided tissue acquisition
• genome sequencing
• next-generation sequencing
• pancreatic cancer
• precision medicine

Endoscopic ultrasound/ultrasonography‐guided biliary drainage (EUS‐BD) is a relatively new modality for biliary drainage after failed or difficult transpapillary biliary cannulation. Despite its clinical utility, EUS‐BD can be complicated by severe adverse events such as bleeding, perforation, and peritonitis. The aim of this paper is to provide practice guidelines for safe performance of EUS‐BD as well as safe introduction of the procedure to non‐expert centers. The guidelines comprised patient–intervention–comparison–outcome‐formatted clinical questions (CQs) and questions (Qs), which are background statements to facilitate understanding of the CQs. A literature search was performed using the PubMed and Cochrane Library databases. Statement, evidence level, and strength of recommendation were created according to the GRADE system. Four committees were organized: guideline creation, expert panelist, evaluation, and external evaluation committees. We developed 13 CQs (methods, device selection, supportive treatment, management of adverse events, education and ethics) and six Qs (definition, indication, outcomes and adverse events) with statements, evidence levels, and strengths of recommendation. The guidelines explain the technical aspects, management of adverse events, and ethics of EUS‐BD and its introduction to non‐expert institutions.

• Biliary stricture
• EUS-guided biliary drainage
• Endoscopic ultrasonography
• Interventional EUS

• EUS-BD
• EUS-HGS
• endoscopic ultrasound

• EUS-guided biliary drainage
• choledocholithiasis
• endoscopic retrograde cholangiopancreatography
• endoscopic ultrasonography (EUS)
• malignant biliary obstruction

• Adult
• Aged
• Aged, 80 and over
• Cholangiopancreatography, Endoscopic Retrograde
• Cholestasis/diagnosis
• Cholestasis/therapy
• Drainage
• Endosonography
• Female
• Humans
• Male
• Middle Aged
• Patient Selection
• Retrospective Studies
• Treatment Failure
• Young Adult

• EUS-FNA
• EUS-guided
• EUS-guided biliary drainage
• endoscopic ultrasound-guided hepaticogastrostomy

• Biliary drainage
• Consortium
• Endoscopic ultrasound
• Endoscopic ultrasound-guided
• Endoscopic ultrasound-guided biliary drainage
• Pancreatic drainage

• Biliary Tract Diseases/diagnostic imaging
• Biliary Tract Diseases/therapy
• Choledochostomy/adverse effects
• Choledochostomy/methods
• Choledochostomy/standards
• Decompression/adverse effects
• Decompression/methods
• Decompression/standards
• Drainage/adverse effects
• Drainage/methods
• Drainage/standards
• Endosonography/standards
• Gastrostomy/adverse effects
• Gastrostomy/methods
• Gastrostomy/standards
• Humans
• Pancreatic Diseases/diagnostic imaging
• Pancreatic Diseases/therapy
• Practice Guidelines as Topic
• Predictive Value of Tests
• Treatment Outcome
• Ultrasonography, Interventional/standards

Since the introduction of endoscopic ultrasound (EUS) in the 1990s, it has evolved from a primarily diagnostic modality into an instrument that can be used in various therapeutic interventions. EUS-guided fine-needle injection was initially described for celiac plexus neurolysis. By using the fundamentals of this method, drainage techniques emerged for the biliary and pancreatic ducts, fluid collections, and abscesses. More recently, EUS has been used for ablative techniques and injection therapies for patients with for gastrointestinal malignancies. As the search for minimally invasive techniques continued, EUS-guided hemostasis methods have also been described. The technical advances in EUS-guided therapies may appear to be limitless; however, in many instances, these procedures have been described only in small case series. More data are required to determine the efficacy and safety of these techniques, and new accessories will be needed to facilitate their implementation into practice.

• Endoscopic ultrasound-guided drainage
• Endoscopic ultrasound-guided intervention
• Endosonography
• Therapeutic endoscopy

• biliary drainage
• choledocho
• endoscopic ultrasound-guided

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) has become an alternative method after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP) treatment. We present a case series study and its feasibility by using only a linear therapeutic channel echoendoscope to create both a biliary-enteral fistula and anatomic enteral recanalization.

We presented seven cases of unresectable periampullary cancer with both biliary and duodenal obstruction. In these cases, the EUS-guided technique might be an alternative to double stenting (biliary and enteral) in the same procedure and equipment.

In all cases, the location of the biliary obstruction was in the distal common bile duct (CBD) and the grade of proximal dilation diameter varied from 15 mm to 20 mm. Two patients had type I (28.6%) and five had type II (71.4%) duodenal obstruction. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Biliary drainage was effective clinically as well as in laboratory in 6 cases (6/7), by relieving obstructive jaundice and decreasing bilirubin levels.

EUS equipment may offer an alternative to double stenting in the same procedure and with palliative propose.

• choledochoduodenostomy
• endoscopic retrograde cholangiopancreatography
• endoscopic ultrasound
• periampullary cancer

Endoscopic retrograde cholangiography (ERCP) is widely used as a first-line therapy for biliary drainage. ERCP occasionally fails owing to anatomical or technical problems, despite high reported success rates. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has recently emerged as an effective alternative biliary drainage method after unsuccessful ERCP. EUS-BD can be essentially divided into 3 different techniques—(1) EUS-guided transluminal biliary drainage including choledocoduodenostomy and hepaticogastrostomy, (2) EUS-rendezvous technique, and (3) EUS-antegrade approach. Here, we focus on the current status of EUS-BD in light of these 3 different techniques.

• Antegrade
• Biliary drainage
• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasound
• Rendezvous

Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

• Biliary stricture
• Cholangiopancreatography, endoscopic retrograde
• Endoscopic ultrasound guided biliary drainage
• Endosonography

• Endoscopic ultrasound
• fine-needle aspiration
• multidetector helical computed tomography
• neuroendocrine tumor
• pancreatic cancer
• pancreatic cyst

• Asia, Southeastern/epidemiology
• Bile Duct Neoplasms/diagnosis
• Bile Duct Neoplasms/epidemiology
• Bile Duct Neoplasms/therapy
• Cholangiocarcinoma/diagnosis
• Cholangiocarcinoma/epidemiology
• Cholangiocarcinoma/therapy
• Cholangiopancreatography, Endoscopic Retrograde
• Drainage/methods
• Endoscopy/methods
• Asia, Eastern/epidemiology
• Female
• Hepatic Duct, Common/pathology
• Humans
• Klatskin Tumor/diagnosis
• Klatskin Tumor/epidemiology
• Klatskin Tumor/therapy
• Male

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7^th, 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting’s agenda and the conclusions generated by the creation of this consortium group.

• Endoscopic ultrasound
• Biliary drainage
• Endosonography-guided cholangiopancreatography
• Endoscopic ultrasound guided
• Pancreatic drainage
• Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangio-pancreatography is the most appropriate technique for treating common bile duct and pancreatic duct stenosis secondary to benign and malignant diseases. Even if the procedure is performed by skillful endoscopist, there are patients in whom endoscopic stent placement is not possible. Common causes of failure include complex peri-papillary diverticula, prior surgery procedures, tumor involvement of the papilla, biliary sphincter stenosis, and impacted stones. Percutaneous trans-hepatic biliary drainage (PTBD) and surgical intervention carry morbidity and mortality. Recently endoscopic ultrasonography-guided biliary drainage has been reported as an alternative technique. Endoscopic ultrasonography-guided biliary drainage using either direct access or a rendezvous technique has attracted attention as an alternative procedure to PTBD, with a technical success between 75%-100% and with low complication rate. We have reviewed published data on EUS guided biliary drainage procedures with the aim of summarizing the efficacy and safety of this promising method.

• Interventional endoscopic ultrasonography
• Endoscopic ultrasonography drainage
• Biliary drainage
• Endoscopic retrograde cholangio-pancreatography

Since endoscopic ultrasound (EUS) was developed in the 1990s, EUS has become widely accepted as an imaging tool. EUS is categorized into radial and linear in design. Radial endoscopes provide cross-sectional imaging of the mediastinum, gastrointestinal tract, liver, spleen, kidney, adrenal gland, and pancreas, which has highly accuracy in the T and N staging of esophageal, lung, gastric, rectal, and pancreatic cancer. Tumor staging is common indication of radial-EUS, and EUS-staging is predictive of surgical resectability. In contrast, linear array endoscope uses a side-viewing probe and has advantages in the ability to perform EUS-guides fine needle aspiration (EUS-FNA), which has been established for cytologic diagnosis. For example, EUS-FNA arrows accurate nodal staging of esophageal cancer before surgery, which provides more accurate assessment of nodes than radial-EUS imaging alone. EUS-FNA has been also commonly used for diagnose of pancreatic diseases because of the highly accuracy than US or computed tomography. EUS and EUS-FNA has been used not only for TNM staging and cytologic diagnosis of pancreatic cancer, but also for evaluation of chronic pancreatitis, pancreatic cystic lesions, and other pancreatic masses. More recently, EUS-FNA has developed into EUS-guided fine needle injection including EUS-guided celiac plexus neurolysis, celiac plexus block, and other “interventional EUS” procedures. In this review, we have summarized the new possibilities offered by “interventional EUS”.

• Endoscopic ultrasound-fine needle aspiration
• Interventional endoscopic ultrasound

• Duodenal stent
• Endoscopic ultrasonography-guided choledochoduodenostomy
• Malignant biliary obstruction

• Duodenal stent
• Endoscopic ultrasonography-guided choledochoduodenostomy
• Malignant biliary obstruction

AIM: To determine the utility of endoscopic ultrasound-guided biliary drainage (EUS-BD) with a fully covered self-expandable metal stent for managing malignant biliary stricture.

METHODS: We collected data from 13 patients who presented with malignant biliary obstruction and underwent EUS-BD with a nitinol fully covered self-expandable metal stent when endoscopic retrograde cholangiopancreatography (ERCP) fails. EUS-guided choledochoduodenostomy (EUS-CD) and EUS-guided hepaticogastrostomy (EUS-HG) was performed in 9 patients and 4 patients, respectively.

RESULTS: The technical and functional success rate was 92.3% (12/13) and 91.7% (11/12), respectively. Using an intrahepatic approach (EUS-HG, n = 4), there was mild peritonitis (n = 1) and migration of the metal stent to the stomach (n = 1). With an extrahepatic approach (EUS-CD, n = 10), there was pneumoperitoneum (n = 2), migration (n = 2), and mild peritonitis (n = 1). All patients were managed conservatively with antibiotics. During follow-up (range, 1-12 mo), there was re-intervention (4/13 cases, 30.7%) necessitated by stent migration (n = 2) and stent occlusion (n = 2).

CONCLUSION: EUS-BD with a nitinol fully covered self-expandable metal stent may be a feasible and effective treatment option in patients with malignant biliary obstruction when ERCP fails.

• Endoscopic ultrasound-guided
• Biliary drainage
• Metal stent
• Biliary obstruction

Background and Aim. EUS-guided intervention (EGI) for biliary therapy has been increasingly used in recent years. This report aims to describe the spectrum and experience of EUS-guided interventions in biliary diseases in a single-tertiary center. Methods. All patients with EGI were analyzed retrospectively by retrieving data from a prospectively stored endoscopic database between January 2006 and September 2010. Results. There were 31 cases with EGIs (17 female, 14 male) with a mean age ± SD of 58.03 ± 16.89 years. The majority of cases (17/31; 55%) were ampullary or pancreatic cancers with obstructive jaundice. The major indications for EGI were obstructive jaundice (n = 16) and cholangitis (n = 9). The EGIs were technically successful in 24 of the 31 cases (77%). The success rate for the first 3 years was 8 of 13 procedures (61.5%) as compared to that of the last 2 years (16/18 procedures (89%); P = 0.072). Twenty-three of the 24 cases (96%) with technical success for stent placement also had clinical success in terms of symptom improvement. The complications were major in 4 (13%) and minor in 7 (23%) patients. Conclusion. The EUS-guided drainage for biliary obstruction, acute cholecystitis, bile leak, and biloma was an attractive alternative and should be handled in expert centers.

To demonstrate a comprehensive review of published articles regarding endoscopic ultrasound (EUS)-guided biliary drainage.

Review of studies regarding EUS-guided biliary drainage including case reports, case series and previous reviews.

EUS-guided hepaticogastrostomy, coledochoduodenostomy and choledoantrostomy are advanced biliary and pancreatic endoscopy procedures, and together make up the echo-guided biliary drainage. Hepaticogastrostomy is indicated in cases of hilar obstruction, while the procedure of choice is the coledochoduodenostomy or choledochoantrostomy in distal lesions. Both procedures must be performed only after unsuccessful ERCPs. The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian.

Hepaticogastrostomy and coledochoduodenostomy or choledochoantrostomy are feasible when performed by endoscopists with expertise in biliopancreatic endoscopy. Advanced echo-endoscopy should currently be performed under a rigorous protocol in educational institutions.

• Biliary tract
• Drainage
• Endosonography
• Gastrointestinal endoscopy
• Obstructive jaundice

• EUS-Guided Choledochoduodenostomy (EUS-CDS)
• ampullary cancer
• biliary obstruction
• duodenal obstruction
• failed ERCP
• metallic stents

Endoscopic ultrasound (EUS)-guided biliary drainage has emerged as a minimally invasive alternative to percutaneous and surgical interventions for patients with biliary obstruction who had failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-guided biliary drainage has become feasible due to the development of large channel curvilinear therapeutic echo-endoscopes and the use of real-time ultrasound and fluoroscopy imaging in addition to standard ERCP devices and techniques. EUS-guided biliary drainage is an attractive option because of its minimally invasive, single step procedure which provides internal biliary decompression. Multiple investigators have reported high success and low complication rates. Unfortunately, high quality prospective data are still lacking. We provide detailed review of the use of EUS for biliary drainage from the perspective of practicing endoscopists with specific focus on the technical aspects of the procedure.

• Bile duct
• Biliary obstruction
• Biliary drainage
• Endoscopic ultrasound
• Endoscopic ultrasound-guided biliary drainage

• Bile Ducts/diagnostic imaging
• Bile Ducts/surgery
• Cholangiopancreatography, Endoscopic Retrograde
• Choledochostomy/adverse effects
• Choledochostomy/methods
• Cholestasis/diagnostic imaging
• Cholestasis/etiology
• Cholestasis/surgery
• Drainage/methods
• Endosonography/methods
• Female
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Prospective Studies
• Risk Factors
• Stents
• Time Factors
• Treatment Failure

• Anastomosis
• Drainage
• Endoscopic ultrasonograpy
• Intervention
• Neurolysis

The technical advances in endoscopic ultrasonograpy (EUS) and accessories have enabled performing EUS-guided intervention in the pancreas and biliary tract. Many research centers have been performing or investigating EUS-guided drainage, EUS-guided celiac plexus neurolysis and block, EUS-guided anastomosis that includes choledocho-enterostomy and choledocho-gastrostomy, EUS-guided ablation and injection therapy mainly for pancreatic neoplasm, EUS-guided photodynamic therapy and EUS-guided brachytherapy. Some of these are currently clinical applications and others are under investigations in clinical studies or animal models. Further detailed randomized controlled clinical trials and the development of materials will bring us into a new era of therapeutic EUS.

• Anastomosis
• Drainage
• Endoscopic ultrasonograpy
• Intervention
• Neurolysis

• Bile Duct Diseases/therapy
• Cholangiopancreatography, Endoscopic Retrograde
• Endoscopy, Digestive System
• Endosonography
• Humans
• Magnetic Resonance Imaging, Interventional
• Pancreatic Diseases/therapy