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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 166-168

Endoscopic ultrasonography-guided antegrade stenting in surgically altered anatomy: Case report and review of literature

Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission15-May-2022
Date of Decision14-Jun-2022
Date of Acceptance21-Jun-2022
Date of Web Publication13-Oct-2022

Correspondence Address:
Akash Shukla
Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharastra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_16_22

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Endoscopic ultrasonography-guided biliary drainage (EUS-BD) remains an alternative to Endoscopic retrograde cholangiopancreatography (ERCP) for malignant extrahepatic biliary obstruction. Biliary drainage in altered surgical anatomy remains a challenge to endoscopists. Enteroscopy-assisted ERCP (eERCP) has been utilised for biliary access in patients with altered surgical anatomy, but with suboptimal results. We report a case of 51-year-old male, a case of carcinoma stomach undergone distal D2 gastrectomy with gastrojejunostomy with distal biliary obstruction, who underwent EUS-BD antegrade approach with technical and clinical success, with a review of literature of EUS BD in altered surgical anatomy.

Keywords: Endoscopic ultrasonography-guided biliary drainage, endoscopic ultrasound, malignant extrahepatic biliary obstruction

How to cite this article:
Patra BR, Sundaram S, Irtaza M, Rao PK, Kale A, Shukla A. Endoscopic ultrasonography-guided antegrade stenting in surgically altered anatomy: Case report and review of literature. Gastroenterol Hepatol Endosc Pract 2022;2:166-8

How to cite this URL:
Patra BR, Sundaram S, Irtaza M, Rao PK, Kale A, Shukla A. Endoscopic ultrasonography-guided antegrade stenting in surgically altered anatomy: Case report and review of literature. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Nov 27];2:166-8. Available from: http://www.ghepjournal.com/text.asp?2022/2/4/166/358470

  Introduction Top

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) is a method of biliary drainage in patients with obstructive jaundice who have either impossible or failed endoscopic retrograde cholangiopancreatography (ERCP)-guided stent placement. Multiple studies have reported comparable technical and functional success with ERCP.[1] Biliary drainage in altered surgical anatomy remains a challenge to endoscopists. With the evolution of EUS-BD, drainage in these patients has become easier. Percutaneous transhepatic biliary drainage (PTBD) remains an alternative mode of biliary drainage, however, it has reported morbidity as high as 15% and mortality rates up to 4.9%.[2] Here, we report a case of biliary drainage by EUS-guided antegrade approach in a patient with metastatic adenocarcinoma of the stomach who had undergone distal gastrectomy with a review of literature of EUS-BD in altered surgical anatomy.

  Case Report Top

A 51-year-old male patient presented with carcinoma of the stomach diagnosed 18 months ago. He received neoadjuvant chemotherapy with three cycles of epirubicin-oxaliplatin-capecitabine (EOX regimen). He underwent distal gastrectomy with Roux-en-Y gastrojejunostomy, followed by adjuvant chemotherapy with three cycles of EOX regimen. After a disease-free interval of 1½ years, he presented with jaundice with pruritus. Total bilirubin was 7.38 mg/dL and alkaline phosphatase was 779 IU/L. Magnetic resonance imaging with magnetic resonance cholangiopancreatography showed an enlarged lymph node in the precaval region, adjacent to the duodenum and pancreas measuring 3.3 cm × 3.8 cm compressing the lower common bile duct (CBD) and causing upstream dilatation of CBD and intrahepatic biliary radical [Figure 1]. Computed tomography (CT)-guided lymph node biopsy showed metastatic adenocarcinoma. After discussions in the multidisciplinary team meeting, the patient was planned for antegrade EUS-BD. The procedure was performed under general anesthesia after informed consent. Using a curved linear echoendoscope (Olympus GF-UCT 180), the intrahepatic bile duct in segment II was visualized from the gastric remnant transgastrically [Figure 2]a. After confirming an avascular tract, a 19 G fine-needle aspiration (FNA) needle (Expect 19G FNA needle; Boston Scientific) was used to puncture the bile duct. After removing the stylet and aspiration of bile, the contrast was injected into the biliary system and a cholangiogram was taken, which revealed a distal CBD stricture [Figure 2]b. Then, a guidewire was passed through the stricture and papilla into the duodenum [Figure 2]c. The tract was dilated using a 6Fr cystotome. The contrast was injected again through the cystotome to confirm the length of stricture and duodenal position for appropriate stent placement [Figure 2]d. Subsequently, a 6 cm self-expanding metallic stent (SEMS) (WallStent; Boston Scientific) was placed under fluoroscopic guidance across the stricture [Figure 2]e. The procedure was uneventful and he was observed for 1 day and then discharged. Serum bilirubin got normalized after 2 weeks of EUS-BD and a repeat contrast-enhanced CT of the abdomen confirmed the position of the stent [Figure 3]. Subsequently, the patient received four cycles of capecitabine and irinotecan hydrochloride regimen as palliative chemotherapy. In view of progressive disease, he received four cycles of single-agent docetaxel. The patient succumbed to the disease after 40 months of SEMS placement without any stent-related complications.
Figure 1: Three-dimensional reconstruction of magnetic resonance cholangiopancreatography showing distal common bile duct obstruction with upstream biliary dilatation

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Figure 2: (a) Segment II radicles as visualized on EUS (arrow), (b) Puncture of intrahepatic biliary radicle with contrast injection to delineate distal CBD obstruction, (c) Passage of guide-wire across the distal CBD stricture, (d) Delineation of duodenum after passage of cystotome to dilate tract, (e) Placement of SEMS across the distal CBD stricture with drainage of contrast

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Figure 3: CT showing necrotic portocaval node (arrow) with patent stent

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  Discussion Top

EUS-BD is being increasingly used as a primary treatment modality, especially in malignant obstruction.[3] While multiple studies have established EUS-BD as a second-line rescue procedure in malignant distal biliary obstruction, there is sparse data regarding its effectiveness as a primary modality.[3] A meta-analysis comparing ERCP with EUS-BD in malignant distal biliary obstruction by Han et al.[4] showed high and comparable clinical and technical success rates for both procedures (ERCP: 95.7% and 96.5%, EUS-BD: 93.8% and 94.8%). The adverse event (AE) rates were also comparable (18.3% for ERCP and 16.3% for EUS-BD). Ikeuchi and Itoi[5] reviewed various types of EUS-BD and reported a technical success rate approaching 100% for EUS-guided antegrade stenting (EUS-AGS) approach. He further showed comparable clinical success and complication rates among EUS-AGS, EUS-guided hepatogastrostomy, and EUS-guided choledocoduodenostomy. Another meta-analysis was done by Hathorn et al.[3] evaluating EUS-BD as a primary modality of treatment for malignant biliary obstruction showed clinical success, technical success, and AE rates were 97%, 95%, and 19%, respectively.

In malignant biliary obstruction, the various approaches of biliary drainage are described in the image [Figure 4].[6]
Figure 4: Approach to a patient planned for EUS-BD. EUS-Rv: Endoscopic ultrasonography-guided rendezvous, EUS-CDS: Endoscopic ultrasonography-guided choledochoduodenostomy, EUS-HGS: Endoscopic ultrasonography-guided hepaticogastrostomy, EUS-AG: EUS-guided antegrade

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In surgically altered anatomy, the approach of biliary drainage depends on the type of surgery performed hence the accessibility to the papilla. In patients who had underwent Billroth I, distal gastrectomy and sleeve gastrectomy standard ERCP procedure can be performed due to continuity of native anatomy and usual accessibility of papilla. The other usual types of surgically altered anatomy are Billroth II, Whipple anatomy and Roux-en-Y gastric bypass, and Roux-en-Y hepaticojejunostomy. In Billroth II reconstructed anatomy, standard ERCP can be performed based on the length of afferent limb or else antegrade approach or hepatogastrostomy can be done. In Whipple anatomy, Roux-en-Y gastric bypass, and Roux-en-Y hepaticojejunostomy, an antegrade and hepatogastrostomy approach are feasible for biliary drainage. In our patient, antegrade approach was preferred over hepatogastrostomy in view of the high complication rate in the later (22% vs. 5%).[5] The main challenge during antegrade drainage is to maintain the original scope position and closely appose the scope tip throughout the procedure after accessing the bile duct with FNA needle.

Siripun et al. evaluated the efficacy of EUS-BD and reported clinical success, technical success, and AE rates of 91.07%, 89.18%, and 17.5%, respectively.[7] The other modality of biliary access in altered anatomy is enteroscopy-assisted ERCP (e-ERCP), but with suboptimal results.[8] A comparative study in surgically altered anatomy was done by Khashab et al. comparing EUS-BD and e-ERCP.[9] He reported technical success, clinical success, and AE rates (EUS-BD: 98%, 88%, and 20%, and ERCP: 65.3%, 59.1%, and 4%).

There is limited data of EUS-BD in patients with surgically altered anatomy and its role is not defined as an alternative drainage procedure. In our patient, we used EUS-BD antegrade approach with technical and clinical success without any procedure-related AE. EUS-BD has higher clinical success and fewer AE compared to PTBD hence was preferred by our patient. e-ERCP was not preferred due to higher procedural time and lower rates of clinical and technical success.

To conclude, in altered surgical anatomy patients, EUS-BD can be considered a primary modality for biliary drainage. Data comparing EUS-BD and e-ERCP in altered anatomy are sparse. EUS-BD although has higher technical and clinical success, is associated with increased AEs. Patient selection is the key to safe and effective EUS-BD in a patient with altered anatomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Moss AC, Morris E, Mac Mathuna P. Palliative biliary stents for obstructing pancreatic carcinoma. Cochrane Database Syst Rev 2006;(1):CD004200.  Back to cited text no. 1
Kühn JP, Busemann A, Lerch MM, Heidecke CD, Hosten N, Puls R. Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts. AJR Am J Roentgenol 2010;195:851-7.  Back to cited text no. 2
Hathorn KE, Bazarbashi AN, Sack JS, McCarty TR, Wang TJ, Chan WW, et al. EUS-guided biliary drainage is equivalent to ERCP for primary treatment of malignant distal biliary obstruction: A systematic review and meta-analysis. Endosc Int Open 2019;7:E1432-41.  Back to cited text no. 3
Han SY, Kim SO, So H, Shin E, Kim DU, Park DH. EUS-guided biliary drainage versus ERCP for first-line palliation of malignant distal biliary obstruction: A systematic review and meta-analysis. Sci Rep 2019;9:16551.  Back to cited text no. 4
Ikeuchi N, Itoi T. Endoscopic ultrasonography-guided biliary drainage: An alternative to percutaneous transhepatic puncture. Gastrointest Interv 2015;4:31-9.  Back to cited text no. 5
Hawes R, Fockens P, Varadarajulu S. Endosonography. In: Endoscopic Ultrasonography-Guided Drainage of the biliary-Pancreatic Ductal Systems and Gallbladder. 4th ed., Ch. 24. Elsevier Publication; 2018. p. 303. Available from: https://www.elsevier.com/books/endosonography/9780323547239. [Last accessed on 2022 Jun 28].  Back to cited text no. 6
Siripun A, Sripongpun P, Ovartlarnporn B. Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy. World J Gastrointest Endosc 2015;7:283-9.  Back to cited text no. 7
Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 2013;77:593-600.  Back to cited text no. 8
Khashab MA, El Zein MH, Sharzehi K, Marson FP, Haluszka O, Small AJ, et al. EUS-guided biliary drainage or enteroscopy-assisted ERCP in patients with surgical anatomy and biliary obstruction: an international comparative study. Endosc Int Open 2016;4:E1322-7.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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