Endoscopic Ultrasound Guided Biliary Drainage in Malignant Distal Biliary Obstruction

SIMPLE SUMMARY: EUS-guided biliary drainage (EUS-BD) has proven effective in the palliation of malignant biliary obstructions. There are several methods for obtaining EUS-guided biliary drainage when endoscopic retrograde cholangiopancreatography (ERCP) fails. To date, EUS-BD, along with the well-established role of percutaneous transhepatic biliary drainage (PTBD) and surgical hepaticojejunostomy, has been demonstrated as a viable palliative treatment option in these patients. There are no specific guidelines with regard to the optimal drainage method. In this review, we compare all these techniques, demonstrating that EUS-BD in expert hands represents a minimally invasive and effective method in the palliative treatment of patients with malignant biliary obstruction. ABSTRACT: Malignant biliary obstruction (MBO) is a challenging medical problem that often negatively impacts the patient’s quality of life (QoL), postoperative complications, and survival rates. Endoscopic approaches to biliary drainage are generally performed by ERCP or, in selected cases, with a percutaneous transhepatic biliary drainage (PTBD). Recent advances in therapeutic endoscopic ultrasound (EUS) allow drainage where previous methods have failed. EUS has evolved from a purely diagnostic technique to one that allows a therapeutic approach in the event of ERCP failure in distal MBO. Moreover, the introduction of dedicated accessories and prostheses for EUS-guided transmural biliary drainage (EUS-BD) made these procedures more successful with regard to technical success, clinical outcomes and reduction of adverse events (AEs). Finally, lumen-apposing metal stents (LAMS) have improved the therapeutic role of the EUS. Subsequently, the electrocautery enhanced tip of the LAMS (EC-LAMS) allows a direct access of the delivery system to the target lumen, thereby simplifying and reducing the EUS-BD procedure time. EUS-BD using LAMS and EC-LAMS has proven effective and safe with a low rate of AEs. This review aims to evaluate biliary drainage techniques in malignant obstruction, focusing on the role of EUS biliary drainage by LAMS.