Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Figure 1 Graphical representation of surgical altered anatomy. A: Billroth II anatomy; B: Billroth II anatomy with Braun anastomosis; C: Roux-en-Y Hepaticojejunostomy; D: Post-Whipple surgery anatomy; E: Roux-en-Y Gastric Bypass anatomy.

Figure 2 Endoscopic ultrasound guided transhepatic rendezvous in a case of carcinoma stomach post distal gastrectomy with intraoperative bile duct injury. A: Puncture and passage of wire from segment II in left hepatic duct with proximal common bile duct stricture; B: Guide-wire passed across the papilla after tract was dilated with cystotome; C: Scope changed to upper gastrointestinal (GI) endoscope and passed till the level of the papilla; D: Bilateral plastic stent placement using upper GI endoscope.

Figure 3 Endoscopic ultrasound guided Hepaticogastrostomy in case of right hepatectomy with extrahepatic biliary tract excision with left hepatiojejunostomy with stenosis with new onset recurrence in left lobe. A: Computed tomography scan showing dilated left intrahepatic biliary radicles with hypodense lesion in segment II; B: Puncture from segment III with 19G FNA needle; C: Covered self- expandable metal stent (SEMS) placed across the hepaticogastrostomy tract; D: Endoscopic view of SEMS protruding in the proximal stomach with drainage of bile.

Figure 4 Endoscopic ultrasound guided antegrade self- expandable metal stent placement in a patient post subtotal gastrectomy with recurrence in portocaval lymph node with proximal common bile duct obstruction with inaccessible papilla. A: Puncture into segment II radicle with 19G FNA needle; B: Cholangiogram showing Bismuth type I block; C: Self- expandable metal stent placement across the papilla with drainage of contrast.

Figure 5 Algorithm for endoscopic ultrasound guided intervention in patients with surgically altered anatomy. AG: Antegrade stenting; BBS: Benign biliary stricture; CDS: Choledochoduodenostomy; EUS RV: Endoscopic ultrasound rendezvous; HGS: Hepaticogastrostomy; EDGE: Endoscopic Ultrasound Directed Transgastric ERCP; RYHJ: Roux-en-Y hepaticojejunostomy; RYGB: Roux-en-Y gastric bypass.