Endoscopy 2010; 42(3): 232-236
DOI: 10.1055/s-0029-1243858
Case report/series

© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound (EUS)-guided transhepatic anterograde self-expandable metal stent (SEMS) placement across malignant biliary obstruction

T.  Nguyen-Tang1 , K.  F.  Binmoeller1 , A.  Sanchez-Yague1 , J.  N.  Shah1
  • 1Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
Further Information

Publication History

submitted 9 November 2009

accepted after revision 18 November 2009

Publication Date:
29 January 2010 (online)

Endoscopic retrograde cholangiopancreatography (ERCP) with placement of self-expandable metal stents (SEMS) for palliation of malignant obstruction may not be possible in patients with an inaccessible biliary orifice. Endoscopic ultrasound (EUS)-guided drainage methods may be useful in this setting. This study aimed to determine the outcomes of EUS-guided anterograde SEMS placement across malignant strictures in patients with an inaccessible biliary orifice. Over a 2-year period, procedural and outcomes data on all patients undergoing EUS-guided anterograde SEMS drainage after failed ERCP were prospectively entered into a database and reviewed. Five patients underwent EUS-guided anterograde SEMS. Indications included: advanced pancreatic cancer (n = 3), metastatic cancer (n = 1), and anastomotic stricture (n = 1). The biliary orifice could not be reached endoscopically due to duodenal stricture (n = 4) or inaccessible hepaticojejunostomy (n = 1). EUS-guided punctures were performed transgastrically into left intrahepatic ducts (n = 4) or transbulbar into the common bile duct (n = 1). Guide wires were passed and SEMS were successfully deployed across strictures in an anterograde fashion in all patients. Jaundice resolved and serum bilirubin levels decreased in all cases. No procedure-related complications were noted during a mean follow-up of 9.2 months. EUS-guided anterograde SEMS placement appears to be a safe and efficient technique for palliation of biliary obstruction in patients with an endoscopically inaccessible biliary orifice. The procedure can be performed at the time of failed standard ERCP, and provides an alternative drainage option to percutaneous or surgical decompression and to EUS-guided creation of bilioenteric fistulae.


J. N. Shah, MD 

Interventional Endoscopy Services
California Pacific Medical Center

2351 Clay Street
San Francisco, CA 94115

Fax: +1-415-6001416

Email: shahj@sutterhealth.org