Different options of endosonography-guided biliary drainage after endoscopic retrograde cholangio-pancreatography failure

Figure 1 The systematic endosonography-guided biliary drainage approach for endoscopic retrograde cholangiopancreatography failure. PTBD: Percutaneous transhepatic biliary drainage; EUS-CD: Endosonography-guided choledochoduodenostomy; EUS-HG: Endosonography-guided hepaticogastrostomy; EUS-ASI: Endosonography-guided anterograde stent insertion; EUS-RV: Endosonography-guided rendez-vous.

Figure 2 Patient with acute pancreatitis after cholecystectomy and Billroth II gastrectomy. Endosonography (EUS)-guided rendez-vous technique. A: EUS image with dilation of the intrahepatic biliary duct; B: EUS-guided cholangiography; C: Insertion of the guidewire across the duodenal papilla and positioning in the duodenum; D: Capture of the guidewire with a frontal view endoscope; E: Balloon dilatation of the duodenal papilla; F: Insertion of a 10 Fr plastic stent.

Figure 3 Patient with duodenal stenosis due to a pancreatic carcinoma. A: Endosonography (EUS)-guided cholangiography; B: Insertion of the guidewire through the duodenal major papilla and positioning in the duodenum; C: Anterograde insertion of the self-expandable metallic stents (SEMS) through the gastric wall across the duodenal major papilla and its positioning in the duodenum; D: Deployment of the SEMS; E: Insertion of the duodenal SEMS. SEMS: Self-expandable metallic stents.

Figure 4 Endosonography-guided hepatogastrostomy. A: Endosonography (EUS) puncture of the dilated biliary intrahepatic duct; B: EUS-guided cholangiography; C and D: Deployment and positioning of the biliary self-expandable metallic stents (SEMS); E: Endoscopic view of the SEMS through the gastric wall.

Figure 5 Endosonography-guided choledochoduodenostomy. A: Endosonography (EUS) image of the pancreatic carcinoma; B: Puncture of the common bile duct through the duodenum with a 19 gauge aspiration needle; C: Insertion of the self-expandable metallic stents after balloon dilation of the fistula; D: EUS-guided cholangiography through the choledochoduodenostomy.