EUS-GUIDED DOUBLE BILIARY DRAINAGE FOR COMPLEX MALIGNANT HILAR BILIARY OBSTRUCTION

Introduction:

Endoscopic ultrasound guided biliary drainage (EUS BD) is a novel technique to rescue patients who had failed ERCP biliary drainage due to significant stricture or because of surgically altered anatomy.

The situation would be more challenging in the patient who had failed ERCP or incomplete drainage due to high grade malignant hilarity biliary obstruction (MHBO). In those patient percautanaus biliary drainage (PTBD) or EUS BD would be the only options.

For high grade hilar obstruction, the efficacy of EUS hepaticogastrostomy (HGS) for the left intrahepatic duct (IHD) and hepaticoduodonestomy (HDS) for the right IHD drainage were demonstrated in different studies. However number of cases and studies in particular for the right IHD drainage are scarce. On the other side there is no universal consensus on the optimal strategy to perform EUS-BD, and the decision is largely based on the patient's anatomy and level of obstruction.

Here we are demonstrating double EUS -BD, to drain intrahepatic bile ducts in two cases with malignant high grade hilar obstruction.

Method:

In both cases the ERCP drainage failed to provide complete biliary drainage even after the first EUS guided biliary drainage both cases had IHD obstruction so they underwent second IHD biliary drainage which successfully relieve obstructive symptoms.

In those patient we achieved technical success in both cases with no major complication related to the procedure. However our second patient had only partial clinical improvement.

Conclusion:

We believe, double EUS BD for intrahepatic duct drainage is relatively safe and feasible procedure for completion of biliary drainage in complex malignant hilar obstruction.

This procedure need to be done by experienced endosonographic in a tertiary hospital setting.

There is no universal consensus on the optimal strategy to perform EUS-BD and more case studies required.