Case Report
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 14, 2015; 21(34): 10045-10048
Published online Sep 14, 2015. doi: 10.3748/wjg.v21.i34.10045
Endoscopic ultrasound-guided biliary drainage: Bilateral systems drainage via left duct approach
Varayu Prachayakul, Pitulak Aswakul
Varayu Prachayakul, Siriraj GI Endoscopy Center, Division of Gastroenterology, Department of Internal Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
Pitulak Aswakul, Liver and Digestive Institute, Samitivej Sukhumvit Hospital, Bangkok 10120, Thailand
Author contributions: Prachayakul V and Aswakul P contributed equally to the conception and writing of the article, and approved the final version to be published.
Institutional review board statement: Approval was obtained from the ethical committee of the Siriraj Internal Review Board.
Informed consent statement: Informed consent was obtained from the patient.
Conflict-of-interest statement: The authors have no conflicts of interest related to this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Varayu Prachayakul, Associate Professor, Siriraj GI Endoscopy Center, Division of Gastroenterology, Department of Internal Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
Telephone: +66-818654646 Fax: +66-24115013
Received: March 5, 2015
Peer-review started: March 7, 2015
First decision: April 13, 2015
Revised: May 5, 2015
Accepted: June 26, 2015
Article in press: June 26, 2015
Published online: September 14, 2015

Endoscopic ultrasound (EUS)-guided biliary drainage is accepted as a less invasive, alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUS-guided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a roux-en-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed, thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage, both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently, only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma, and thus can be used as an alternative to percutaneous biliary drainage.

Keywords: Biliary drainage, Endoscopic ultrasound-guided, Bilateral systems, Transmural drainage

Core tip: Endoscopic ultrasound-guided left system drainage via hepaticogastrostomy can be performed with > 90% technical and clinical success in patients with obstructive jaundice. A transgastric approach for endoscopic ultrasound-guided hepaticogastrostomy to drain both intrahepatic systems was successfully performed by manipulating the guidewire until it passed across the stricture point; the two systems were then bridged with a metal stent. The authors propose that this technique is feasible and effective for bilateral biliary drainage.