EUS guided biliary drainage

https://doi.org/10.1148/rg.2020190158

Definition: An extra-anatomic drainage route between the gastrointestinal (GI) tract and the biliary system is created with a covered metallic stent or plastic stent.

Indications:

• Conventional transpapillary BD is unsuccessful.
• Unsuccessful placement of a percutaneous biliary stent
• H/o severe acute pancreatitis by transpapillary BD

Types:

• HGS - Hepaticogastrostomy.
• HJS - Hepaticojejunostomy (after gastrectomy), 
• CDS - Choledochoduodenostomy.
• HDS - Hepaticoduodenostomy.
• GBD - EUS gallbladder drainage. 

Checklist:

• Type of biliary obstruction.
• Collateral vessels in the puncture route.
• Ascites.
• Volume of the liver segment.
• Distribution of an intrahepatic tumor.
• GI tract patency.

Bismuth classification

Bismuth classification for biliary stricture in the hilar region:

 

Type I - confluence of the hepatic duct is preserved.

Type II - confluence of the hepatic duct is invaded.  

Type III -  confluence of the second branch of the unilateral hepatic duct is invaded.
         IIIa -  anterior and posterior segments is invaded
         IIIb -  medial and lateral segments is invaded. 

Type IV -  confluence of the second branch of the hepatic duct is invaded bilaterally.

Post-op findings :

• Small amount of intraperitoneal gas.
• Localized edematous change in the GI tract.
• Notch in the placed stent.
• Localized biliary dilatation caused by stent placement.

Stent malfunction causes:

• Impaction of debris and/or food.
• Stent migration into the GI tract.
• Tumor overgrowth and/or hyperplasia.

Complications (11–23%):

• Internal stent migration.
• Intraperitoneal biloma.
• Arterial bleeding or pseudoaneurysm.
• Perforation of the GI tract.
• Portobiliary fistula.