EUS-guided gallbladder drainage (EUS-GBD) is utilized for the treatment of acute cholecystitis and symptomatic cholelithiasis in patients who are poor operative candidates. Over the last several years, improved techniques and accessories have facilitated GBD . Recent literature demonstrated effectiveness and safety of EUS-guided GBD. Available data suggest at least similar results when compared to percutaneous cholecystostomy. EUS-guided GBD can be performed as a primary intervention in patients with cholecystitis who are unfit for urgent surgical intervention and as a secondary intervention to internalize biliary drainage in patients with indwelling percutaneous cholecystostomy catheters. Various stents can be used for -EUS-guided GBD. The optimal device and technique have yet to be determined, although at the present time, the use of luminal apposing stents is preferred. The purpose of this review is to provide the highlights of the most recent literature on EUS-guided GBD.

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EUS-guided biliary drainage (BD) is an option to treat obstructive jaundice when ERCP drainage fails. These procedures represent alternatives to surgery and percutaneous transhepatic BD and have been made possible through the continuous development and improvement of EUS scopes and accessories. The development of linear sectorial array EUS scopes in early 1990 brought a new approach to the diagnostic and therapeutic dimensions of echoendoscopy capabilities, opening the possibility to perform puncture over a direct ultrasonographic view. Despite the high success rate and low morbidity of BD obtained by ERCP, difficulty can arise with an ingrown stent tumor, tumor gut compression, periampullary diverticula, and anatomic variation. The EUS-guided technique requires puncture and contrast of the left biliary tree. When performed from the gastric wall, access is obtained through hepatic segment III. Diathermic dilation of the puncturing tract is performed using a 6F cystotome and a plastic or metallic stent. The technical success of hepaticogastrostomy is near 98%, and complications are present in 15%–20% of cases. The most common complications include pneumoperitoneum, bilioperitoneum, infection, and stent dysfunction. To prevent bile leakage, we used a special partially covered stent (70% covered and 30% uncovered). Over the last 15 years, the technique has typically been performed in reference centers, by groups experienced with ERCP. This seems to be a general guideline for safer execution of the procedure.

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EUS-guided gallbladder drainage (EUS-GBD) is gaining popularity as an option for drainage of the gallbladder in patients suffering from acute cholecystitis but at high risk for cholecystectomy. It allows internal drainage of the gallbladder and avoidance of the external tube as used in percutaneous cholecystostomy (PT-GBD). It may also provide additional benefits, including reduced re-admissions and re-interventions. In this chapter, we review the indications and outcomes of EUS-GBD. Furthermore, the follow-up management of patients that received EUS-GBD would be outlined.

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One of the major roles of interventional EUS is biliary decompression as an alternative to ERCP or percutaneous transhepatic biliary drainage. Among EUS-guided biliary drainage, EUS-guided hepaticogastrostomy with transmural stenting (EUS-HGS) may be the most promising procedure since this procedure can overcome the limitation of ERCP. However, EUS-HGS has disadvantages, and the safety issue is still not resolved. In this review, the clinical outcomes and limitations of EUS-HGS will be discussed.

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EUS-guided biliary drainage (EUS-BD) has been recognized as a new alternative to failed ERCP. The alternatives for failed/impossible ERCP in cases of difficult and selective bile duct cannulation include percutaneous transhepatic BD (PTBD) with precut papillotomy. EUS-BD is reportedly more convenient than PTBD and more successful than precut papillotomy, suggesting that EUS-BD is the next step following failed/impossible ERCP.

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ERCP is the mainstay of therapy for pancreatobiliary diseases in patients with native upper gastrointestinal (UGI) anatomy. However, when UGI anatomy is surgically altered, standard ERCP becomes technically challenging or not possible. In such instances, EUS-guided biliary drainage (EUS-BD) has been increasingly employed by advanced endoscopists as a safe and effective method of access to the biliary tree. In this study, we review the technical aspects and outcomes of EUS-BD in patients with surgical UGI anatomy.

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Hepaticogastrostomy (HGS) has been reported for the management of palliative malignant hilar stricture and involves draining the left liver as rescue therapy. For the management of this complex stenosis, another new option for draining the right liver under EUS guidance was introduced. Ten publications involving 38 patients have been reported in the literature, in which the following two main techniques have been described: direct puncture of the right liver from the bulbus and the bridge technique allowing the drainage of the right liver across the left liver through HGS. In this review, we describe the techniques used and the potential advantages and complications of these procedures. Although this kind of drainage is demanding and probably limited to specific patients, EUS-biliary drainage of the right liver seems feasible with acceptable complications.

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The EUS-guided biliary drainage (EUS-BD) has gained broad acceptance as the preferred approach after failed ERCP for malignant biliary obstruction. Despite the drainage route, namely, transhepatic or transduodenal, the technical and clinical success rates are high. Because of such good outcomes with tolerable adverse events (AEs) rate, the EUS-BD might soon even replace the ERCP for primary biliary decompression in patients at high risk of failed biliary cannulation. Among the EUS-BD techniques, the choledochoduodenostomy seems to carry the lower risk of AEs and should be considered the first-line EUS approach for biliary decompression.

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