• Users Online:445
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 235-243

Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure

1 Department of Surgery, University of Sao Paulo, São Paulo, Brazil
2 Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
3 Weill Cornell Medical College, New York, USA

Date of Submission10-Feb-2015
Date of Acceptance15-Apr-2015
Date of Web Publication17-Aug-2015

Correspondence Address:
Dr. Everson L. A. Artifon
Department of Surgery, University of Sao Paulo, São Paulo
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2303-9027.163010

Rights and Permissions

Background and Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP. Patients and Methods: A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively. Results: Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days). Conclusion: Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction.

Keywords: Biliary duct neoplasms, drainage, endoscopic ultrasound, obstructive jaundice, palliative treatment, pancreatic neoplasms

How to cite this article:
Artifon EL, Loureiro JF, Baron TH, Fernandes K, Kahaleh M, Marson FP. Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure. Endosc Ultrasound 2015;4:235-43

How to cite this URL:
Artifon EL, Loureiro JF, Baron TH, Fernandes K, Kahaleh M, Marson FP. Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure. Endosc Ultrasound [serial online] 2015 [cited 2020 Feb 22];4:235-43. Available from: http://www.eusjournal.com/text.asp?2015/4/3/235/163010

  Introduction Top

Malignant distal bile duct obstruction is an extremely aggressive condition. Most cases are diagnosed at an advanced stage. At the time of diagnosis, approximately 37% of patients have biliary obstruction and approximately 85% of patients are no longer candidates for curative surgical treatment. [1],[2],[3] Due to this advanced stage at presentation, such patients have poor performance status. Relief of obstructive jaundice becomes critical because biliary stasis (direct bilirubin higher than 15 mg/dL) can lead to comorbidities and early death. [4]

Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement is the method of choice for initial palliative treatment of obstructive jaundice, with a success rate of 90-95%. [5],[6] In cases of ERCP failure, surgical bypass is an alternative method, though with recurrent jaundice in 2-5% and a mortality rate of up to 24%. [7] Percutaneous transhepatic biliary drainage is another alternative method for relief of biliary obstruction; however, the rate of complications can reach 30% due to biliary fistulas, bleeding, and hepatic abscesses. [8],[9] Furthermore, some patients require long-term external biliary drains, which poorly affects quality of life. Combining endoscopic ultrasound (EUS) therapy with basic techniques of conventional ERCP, a new alternative to biliary decompression has been described: EUS-guided biliary drainage (EBD). [10],[11],[12] This novel technique carries a technical success rate of 95%. [13],[14]

EBD has not been compared specifically to conventional surgical techniques. In this study, we sought to determine outcome differences between two biliary drainage techniques in patients with distal malignant biliary obstruction and failed ERCP.

  Patients and Methods Top

From March 2011 to September 2013, a total of 1,549 therapeutic ERCPs were performed at the University of Sao Paulo. All patients with distal malignant biliary obstruction undergoing ERCP were consented for possible EBD. In case of ERCP failure, the patient was included in the study according to the inclusion and exclusion criteria. The following two groups were created: The surgical hepaticojejunostomy (HJT) group and the EUS-guided choledochoduodenostomy (CDT) group. The allocation of each included patient to his/her group was found on revealing a sealed envelope, containing the patient`s allocation, just after the ERCP failure. Inclusion criteria included age ≥18 years, unresectable distal malignant obstruction of distal bile duct, and failed standard ERCP. Patients from whom consent had not been obtained and patients with severe coagulopathy were excluded from the study. The institution's ethical committee review board (IRB) approved the study and informed consent forms were presented to all patients. Informed consent was obtained from all subjects after explaining the HJT and EUS-guided CDT techniques, the novel nature of EUS-guided CDT technique, and discussing the risks, complications, alternatives, and possible benefits. The clinical trials registry identified for this study is NCT01522573.

Tumors were classified as unresectable based on MRI results, computerized tomography, and EUS-guided technique (invasion of mesenteric-portal axis to at least 50%, invasion of the superior mesenteric artery, celiac trunk invasion, and evidence of distant metastasis). After ERCP failure, patients were randomized into either of two groups (HJT and CDT), with 16 patients in each group. Patients in the HJT group underwent surgery 1 or 2 days after ERCP failure. The patients in the CDT group underwent EUS-guided CDT immediately after failed ERCP under the same anesthesia session. Patients in the HJT group were monitored by medical assistants in the Department of Surgery, Faculty of Medicine, University of Sao Paulo. Patients in the CDT group were followed up at the Department of Gastrointestinal Endoscopy, Hospital das Clinicas, University of Sao Paulo. All CDT procedures were performed by one endoscopist experienced in ERCP and EUS (ELAA).

Surgical technical success was defined as a successful construction of hepatojejunal anastomosis in Roux-en-Y fashion. The success of EUS-guided technique was characterized by nonanatomical biliary recanalization through the placement of a self-expandable metal stent through the duodenal wall into the bile duct. Clinical success was defined by a reduction of total serum bilirubin (BT) by at least 50% from the initial value after 7 days. BT was measured before and after biliary drainage (7 days, 30 days, 60 days, and 90 days). Quality of life was assessed using the Medical Outcomes Study 36 Index- Item Short-Form Health Survey (SF-36). Median survival time was estimated at up to 3 months according to each technique, with respective intervals with 95% confidence, using the Kaplan-Meier function.

Duodenal invasion of tumor was defined through endoscopic findings (lack of distensibility, mucosal friability, and linear areas in the mucosa located in the middle of the second part of the duodenum and/or bulb with or without decreasing intestinal light) and by EUS (loss of hyperechoic interface between the lesion and the duodenal wall, hypoechoic thickening and loss of echo layers of the duodenal wall under the lesion, and intense neovascularization seen through color Doppler). All patients in the HJT group underwent gastrojejunal bypass (with or without endoscopic signs of duodenal invasion). In the CDT group, patients with endoscopic evidence of duodenal obstruction due to tumor invasion underwent endoscopic placement of enteral self-expanding metallic stent.

Surgical complications assessed included dehiscence of the hepaticojejunal anastomosis and gastroenteroanastomosis, anastomotic ulcer bleeding, hemobilia, cholangitis, and intra-abnominal abscess. EUS-guided drainage complications assessed included abscess formation, abdominal pain, gastrointestinal perforation, hemorrhage, cholangitis, acute pancreatitis, biliary fistula, and stent migration.

After the procedure, patients were followed up for 90 days for clinical complications, laboratory, quality of life, and survival.

Surgical hepaticojejunostomy [Figure 1]
Figure 1. Image showing the final surgical aspect after construction of hepaticocholedochostomy in the Roux-en-Y with gastrojejunal anastomosis. (a) Hepaticojejunal anastomosis (b) Gastrojejunal anastomosis (c) Laterolateral jejunojejunal anastomosis (d) Construction of terminolateral jejunojejunal anastomosis

Click here to view

All procedures were performed under general anesthesia. Intravenous cefazolin (1 gm) was administered prophylactically 1 h before the procedure. A cross section of jejunal loop was taken and a termino-lateral jejuno-jejunal anastomosis (3-4 cm opening) was constructed between the proximal and distal jejunal pouches using 3-0 nylon monofilament suture on a single plane [Figure 1]d. Construction of termino-lateral hepaticojejunal anastomosis with total separate stitches using mononylon 5-0 surgical wire [Figure 1]a was performed. Then construction of latero-lateral gastrojejuno anastomosis with distal segment of the proximal jejunal loop was performed [Figure 1]b. The anastomosis was located at the greater gastric curvature with a 6-cm aperture using 3.0 catgut wire on two levels: The first being with continuous seromuscular stitches and the second, total, also with continuous stitches. Construction of latero-lateral jejuno-jejunal anastomosis between the proximal jejunal and jejunal loop that makes up the Roux-en-Y [Figure 1]c was performed. Temporary drainage of the abdominal cavity was achieved by placing a 20-Fr Penrose drain.

EUS-CDT [Figure 2]
Figure 2. Sequence of images illustrating EUS-guided CDT technique: (a) EUS-guided puncture (b and c) Contrast injection and wire advancement (d) Self-expandable metal stent (SEMS) placement

Click here to view

General anesthesia with tracheal intubation was used to prevent bronchoaspiration. Before the procedure, a single dose of antibiotics was administered.

The dilated common bile duct was identified from the transduodenal route, with the linear echo-endoscope positioned in the duodenal bulb. Color Doppler was used to identify any vascular structures in the path of the needle. Transduodenal puncture of the dilated common bile duct with a 19-gauge needle was performed, and the intraductal position confirmed by aspiration of bile and subsequent cholangiography, delineating biliary anatomy and the stenotic lesion. A 0.035-inch hydrophilic guide wire was passed through the needle.

The needle was then withdrawn, leaving the guide wire in the intraductal position. Dilation of the choledochoduodenal fistula was done using a needle-knife with electrocautery. A self-expandable metallic biliary stent (partially covered) with the distal end positioned in the biliary and proximal end in the duodenal bulb was then placed under endoscopic and fluoroscopic guidance.

All patients remained in fasting and were hospitalized for 1 night for observation.

Statistical analysis

Block randomization was performed using Microsoft Excel 2007 software to randomly allocate patients. Sealed, numbered envelopes were prepared in advance that contained the allocation of each patient. The patient allocations were revealed from the envelopes immediately after ERCP failure. Quantitative personal characteristics were described according to groups using Student's t-tests summary and comparative measurements between techniques. Fisher's exact test or the chi-square test was used to assess the existence of associations, when applicable. Laboratory tests and quality of life scores in each domain were described according to technique and time of evaluation using summary measures, and comparative measurements were made between the techniques and times using generalized estimating equations with a self-regression correlation matrix of order 1 between times, with a normal marginal distribution and logarithm link function to correct high variability. For models that present statistical significance, the analysis was followed by Bonferroni multiple comparison testing in order to evaluate differences between techniques or time differences.

  Results Top

Of the 32 enrolled patients, three (9%) were excluded due to technical failure, one (3%) from the HJT group, and two (7%) from the CDT group. Thus the technical success rate was 93.75% (15/16) in the HJT group and 87.5% (14/16) in the CDT group (P = 0.598). The causes of failure in conventional anatomical access by ERCP are shown in [Table 1].
Table 1. Causes of failure in ERCP

Click here to view

The demographic characteristics of the patients included in this study are presented in [Table 2].
Table 2. Demographic characteristics of the 29 patients

Click here to view

Palliative biliary drainage was performed by means of Roux-en-Y HJT in all patients in the HJT group (15/15). EBD was performed in all patients in the CDT group (14/14) according to the EUS-guided CDT technique.

The mean procedure time in the HJT group was 107 min and in the CDT group was 45.3 min (P = 0.027) [Table 3].
Table 3. Technical data in HJT and CDT groups

Click here to view

Clinical success was achieved in 24/29 patients (83%), i.e., 14 patients (93%) in the HJT group and 10 (71%) in the CDT group (P = 0.169) [Table 4] and [Table 5].
Table 4. Description of the TB, GGT and AP values according to the techniques during follow-up

Click here to view
Table 5. Results of multiple comparisons between times for BT, GGT, FA in both groups

Click here to view

The behavior of laboratory findings according to technique over the follow-up time are depicted in Graphs 1 (BT), 2 [gamma-glutamyl transferase (GGT)], and 3 [alkaline phosphatase (AP)].

Duodenal invasion was observed in five (33.3%) patients in the HJT group. All of them underwent gastric bypass. In the CDT group, duodenal invasion was seen in four patients (28.57%), in which cases enteral metallic stents placed were placed without major complications (P < 0.999).

Regarding quality of life, all areas showed statistically significant improvement (functional capacity, physical health, pain, and social and emotional aspects) independent of the technique used, except for the "general health" and "vitality" technical areas (P > 0.05) [Table 6].
Table 6. Description of scores of quality of life (SF36) according to techniques during follow-up

Click here to view

Complications occurred in two (13.33%) patients in the HJT group: One case of severe bacteremia and one case of gastric bleeding arising from gastroenterostomy. These were successfully treated endoscopically. In the CDT group, three (21.42%) cases of complications were observed: A bleeding duodenal wall, which was treated endoscopically; an early biliary fistula promoting a subhepatic collection of 4 cm, which was successfully treated by nonoperative means; and one case of early stent migration into the abdominal cavity, which was treated surgically. There was no statistically significant difference in the complication rates between techniques (P = 0.651).

The median survival time of patients in the HJT group was 82.27 days, and in the CDT group was 82.36 days. In the HJT group, 60% of the patients died 90 days after surgery, whereas in the CDT group, 42.9% died during the same period (P = 0.389) [Graph 4].

  Discussion Top

For a long period, surgical bypass has been the main modality in the palliation of obstructive jaundice in patients with failed ERCP. However, high rates of morbidity and mortality led to the search for and development of nonsurgical methods for palliative biliary drainage. [15]

Surgical palliation of tumors of the distal bile duct should be performed through the creation of a biliary-enteric anastomosis. However, there is controversy about the choice of the best palliative technique in the malignant obstruction of distal bile duct. In this context, we highlight the HJT, because of the low morbidity and reduced recurrence of jaundice associated with it in the medium term. Cholecystojejunostomy is still a palliative bypass that can be used because it is simple to perform, effective, and presents less morbidity; however, it is limited to patients with intact gallbladder. In this technique, there is the possibility of tumor invasion of the cystic duct, resulting in early biliary obstruction; therefore, it should be used when the estimated survival is, at most, 4-6 months. [18]

Biliary bypass with duodenum is more physiological and is an alternative, besides permitting future endoscopic biliary interventions. However, for malignant lesions, this approach may not be as effective, because there is the risk of anastomosis tumor invasion. [19]

Patients who underwent cholecystojejunostomy presented with lower survival and required more biliary surgery interventions (4.4 × more) compared to those who underwent anastomosis through the principal biliary tract. [20] Of patients with pancreatic head cancer who underwent palliative surgical treatment, 30% required future treatments resulting from duodenal obstruction, thus highlighting why prophylactic gastroenteral bypass is still controversial. [21]

In a meta-analysis published in 2013, patients with malignant pancreatic neoplasm with low surgical risk were most benefited when they underwent surgery, due to the lower rate of recurrent jaundice and subsequently a shorter hospital stay, when compared to patients who underwent bile stent placement. [22]

Regarding survival, patients who underwent palliative surgical biliary drainage, survived, on average, 65 days. [23]

The technical success of EBD by transmural access proves to be 92-95%, [13],[14],[25] while the clinical success, mainly in the CDT, is 75-100%. [14],[24],[25]

A landmark study published in 2012 revealed that there was no significant difference in quality of life among patients with obstructive jaundice caused by malignant biliary disease who underwent CDT and DPTH percutaneous access during the follow-up period of 3 months. [26]

As regards biliary stents, the metallic ones cost more than the plastic stents; however, the patency period of a metallic stent is significantly higher. In addition, partially and fully covered stents seem to be similar in their effectiveness. [27]

The complication rate in CDT is approximately 23%, [25] which can be due to pneumoperitoneum, occlusion of stent, stent migration, and bile leakage. [13],[14],[25] Bile leaks occur more frequently when plastic stents are used (11%). [13]

It is necessary to highlight that EUS-guided drainage is safe and effective when the recommended approaches are followed. [28]

  Conclusion Top

This study demonstrates that surgical HJT and EUS-guided CDT in patients with distal malignant biliary obstruction and failed ERCP are similar regarding the studied outcomes.

  References Top

Boring CC, Squires TS, Tong T, et al. Cancer statistics 1994. CA Cancer J Clin 1994;44:7-26.  Back to cited text no. 1
Bergasa NV. Medical palliation of the jaundiced patient with pruritus. Gastroenterol Clin North Am 2006;35:113-23.  Back to cited text no. 2
Huggett MT, Ghaneh P, Pereira SP. Drainage and bypass procedures for palliation of malignant diseases of the upper gastrointestinal tract. Clin Oncol (R Coll Radiol) 2010;22:755-63.  Back to cited text no. 3
Hatfield AR. Palliation of malignant obstructive jaundice - surgery or stent? Gut 1990;31:1339-40.  Back to cited text no. 4
Huibregtse K. Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and endoscopic biliary and pancreatic drainage. In: Yamada T, Alpers DH, Kalloo AN, et al. editors. e Textbook of Gastroenterology. Philadelphia: JB Lippincott; 1995. p. 2590-617.  Back to cited text no. 5
Kumar S, Sherman S, Hawes RH, et al. Success and yield of second attempt ERCP. Gastrointest Endosc 1995;41:445-7.  Back to cited text no. 6
Trede M. Treatment of pancreatic carcinoma: The surgeon's dilemma. Br J Surg 1987;74:79-80.  Back to cited text no. 7
Ferrucci JT Jr, Mueller PR, Harbin WP. Percutaneous transhepatic biliary drainage: Technique, results, and applications. Radiology 1980;135:1-13.  Back to cited text no. 8
Harbin WP, Mueller PR, Ferrucci JT Jr. Transhepatic cholangiography: Complications and use patterns of the fine-needle technique: A multi-institutional survey. Radiology 1980;135:15-22.  Back to cited text no. 9
Giovannini M, Moutardier V, Pesenti C, et al. Endoscopic ultrasound-guided bilioduodenal anastomosis: A new technique for biliary drainage. Endoscopy 2001;33:898-900.  Back to cited text no. 10
Kahaleh M, Hernandez AJ, Tokar J, et al. Interventional EUS-guided cholangiography: Evaluation of a technique in evolution. Gastrointest Endosc 2006;64:52-9.  Back to cited text no. 11
Artifon EL, Chaves DM, Ishioka S, et al. Echoguided hepatico-gastrostomy: A case report. Clinics (Sao Paulo) 2007;62:799-802.  Back to cited text no. 12
Kawakubo K, Isayama H, Kato H, et al. Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction in Japan. J Hepatobiliary Pancreat Sci 2014;21:328-34.  Back to cited text no. 13
Kim TH, Kim SH, Oh HJ, et al. Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction. World J Gastroenterol 2012;18:2526-32.  Back to cited text no. 14
Agaev BA, Agaev RM, Gasymov RS. The method of biliary tracts drainage of patients with biliodigestive anastomosis at obstructive jaundice and acute cholangitis. Khirurgiia (Mosk) 2011;18-22.  Back to cited text no. 15
Soehendra N, Reynders-Frederix V. Palliative biliary duct drainage. A new method for endoscopic introduction of a new drain. Dtsch Med Wochenschr 1979;104;206-7.  Back to cited text no. 16
Kedia P, Gaidhane M, Kahaleh M. Endoscopic guided biliary drainage: How can we achieve efficient biliary drainage? Clin Endosc 2013;46:543-51.  Back to cited text no. 17
Melo MA, Ramos RP, Lima LM, et al. Anastomose bilio-digestiva por videocirurgia no tratamento paliativo da icterícia obstrutiva dos carcinomas periampulares. Rev Bras Videocir 2007;5:12-8.  Back to cited text no. 18
Moraca RJ. Lee FT, Ryan JA Jr, et al. Long-term biliary function after reconstruction of major bile duct injuries with hepaticoduodenostomy or hepaticojejunostomy. Arch Surg 2002;137:889-94.  Back to cited text no. 19
Cooperman AM, Fader A, Cushin B, et al. Surgery and cancer of pancreas: Will common sense become common practice? Hematol Oncol Clin North Am 2002;16:81-94.  Back to cited text no. 20
Machado MC, Cunha JE, Penteado S, et al. A new technique of gastroenterostomy for palliative treatment of pancreatic head carcinoma. Hepatogastroenterology 2000;47:1741-3.  Back to cited text no. 21
Glazer ES, Hornbrook MC, Krouse RS. A meta-analysis of randomized trials: Immediate stent placement vs. surgical bypass in the palliative management of malignant biliary obstruction. J Pain Symptom Manage 2014;47:307-14.  Back to cited text no. 22
Jievaltas M, Jasenas M, Drigotas M, et al. Results of treatment of extrahepatic cholangiocarcinoma at Kaunas University of Medicine Hospital. Medicina (Kaunas) 2003;39:144-50.  Back to cited text no. 23
Fabbri C, Luigiano C, Fuccio L, et al. EUS-guided biliary drainage with placement of a new partially covered biliary stent for palliation of malignant biliary obstruction: A case series. Endoscopy 2011;43:438-41.  Back to cited text no. 24
Song TJ, Hyun YS, Lee SS, et al. Endoscopic ultrasound-guided choledochoduodenostomies with fully covered self-expandable metallic stents. World J Gastroenterol 2012;18:4435-40.  Back to cited text no. 25
Artifon EL, Aparicio D, Paione JB, et al. Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: Endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage. J Clin Gastroenterol 2012;46:768-74.  Back to cited text no. 26
Itoi T, Isayama H, Sofuni A, et al. Stent selection and tips on placement technique of EUS-guided biliary drainage: Transduodenal and transgastric stenting. J Hepatobiliary Pancreat Sci 2011;18:664-72.  Back to cited text no. 27
Khashab MA, Valeshabad AK, Modayil R, et al. EUS-guided biliary drainage by using a standardized approach for malignant biliary obstruction: Rendezvous versus direct transluminal techniques (with videos). Gastrointest Endosc 2013;78:734-41.  Back to cited text no. 28


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

This article has been cited by
1 Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018
Hiroyuki Isayama,Yousuke Nakai,Takao Itoi,Ichiro Yasuda,Hiroshi Kawakami,Shomei Ryozawa,Masayuki Kitano,Atsushi Irisawa,Akio Katanuma,Kazuo Hara,Takuji Iwashita,Naotaka Fujita,Kenji Yamao,Masahiro Yoshida,Kazuo Inui,Masanori Sugiyama,Keiichi Kubota,Tadahiro Takada
Journal of Hepato-Biliary-Pancreatic Sciences. 2019; 26(7): 249
[Pubmed] | [DOI]
2 EUS-guided antegrade procedures
Shuntaro Mukai,Takao Itoi
Endoscopic Ultrasound. 2019; 8(7): 7
[Pubmed] | [DOI]
3 EUS-guided biliary drainage for postsurgical anatomy
Manol Jovani,Yervant Ichkhanian,Kia Vosoughi,MouenA Khashab
Endoscopic Ultrasound. 2019; 8(7): 57
[Pubmed] | [DOI]
4 Choledochoduodenostomy: Outcomes and limitations
EversonLuiz De Almeida Artifon,ThiagoA. C. Visconti,VitorO Brunaldi
Endoscopic Ultrasound. 2019; 8(7): 72
[Pubmed] | [DOI]
5 Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel
Anthony Y B Teoh,Vinay Dhir,Mitsuhiro Kida,Ichiro Yasuda,Zhen Dong Jin,Dong Wan Seo,Majid Almadi,Tiing Leong Ang,Kazuo Hara,Ida Hilmi,Takao Itoi,Sundeep Lakhtakia,Koji Matsuda,Nonthalee Pausawasdi,Rajesh Puri,Raymond S Tang,Hsiu-Po Wang,Ai Ming Yang,Robert Hawes,Shyam Varadarajulu,Kenjiro Yasuda,Lawrence Khek Yu Ho
Gut. 2018; 67(7): 1209
[Pubmed] | [DOI]
6 Endoscopic Ultrasound Guided Choledocho-Enterostomy by Using Lumen Apposing Metal Stent in Patients with Failed Endoscopic Retrograde Cholangiopancreatography: A Literature Review
Deepanshu Jain,Manan Shah,Upen Patel,Abhinav Sharma,Shashideep Singhal
Digestion. 2018; 98(1): 1
[Pubmed] | [DOI]
7 Endoscopic Ultrasound-Guided Biliary Drainage Using Self-Expandable Metal Stent for Malignant Biliary Obstruction
Lei Lu,Xiaowei Tang,Hangbin Jin,Jianfeng Yang,Xiaofeng Zhang
Gastroenterology Research and Practice. 2017; 2017: 1
[Pubmed] | [DOI]
8 Interventional EUS (with videos)
John T. Maple,Rahul Pannala,Barham K. Abu Dayyeh,Harry R. Aslanian,Brintha K. Enestvedt,Adam Goodman,Sri Komanduri,Michael Manfredi,Udayakumar Navaneethan,Mansour A. Parsi,Zachary L. Smith,Nirav Thosani,Shelby A. Sullivan,Subhas Banerjee
Gastrointestinal Endoscopy. 2017;
[Pubmed] | [DOI]
9 Endoscopic Ultrasonography-Guided Techniques for Accessing and Draining the Biliary System and the Pancreatic Duct
Mihai Rimbas,Alberto Larghi
Gastrointestinal Endoscopy Clinics of North America. 2017; 27(4): 681
[Pubmed] | [DOI]
10 Endoscopic ultrasound-guided biliary drainage: Complications and their management
Hiroyuki Isayama,Yousuke Nakai,Natsuyo Yamamoto,Saburo Matsubara,Yukiko Ito,Hirfoumi Kogure,Tsuyoshi Hamada,Kazuhiko Koike
Gastrointestinal Intervention. 2017; 6(2): 114
[Pubmed] | [DOI]
11 Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing, self-expandable fully covered metal stent for palliative biliary drainage
Joshua Blake French,Adam Wesley Coe,Rishi Pawa
Clinical Journal of Gastroenterology. 2016;
[Pubmed] | [DOI]
12 Endoscopic Ultrasound-Guided Pancreatobiliary Endoscopy in Surgically Altered Anatomy
Pichamol Jirapinyo,Linda S. Lee
Clinical Endoscopy. 2016; 49(6): 515
[Pubmed] | [DOI]
13 Endoscopic ultrasonography-guided choledochojejunostomy: Novel method to treat a severely stenotic choledochojejunal anastomosis
Masataka Kikuyama,Haruna Aoyama,Yusuke Kyoden
Digestive Endoscopy. 2016; 28(2): 221
[Pubmed] | [DOI]
14 Approach to biliary access in patients with altered anatomy
Sudipta D. Chowdhury,Pilar Diez-Redondo,Manuel Perez-Miranda
Techniques in Gastrointestinal Endoscopy. 2016;
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
  Patients and Methods
   Article Figures
   Article Tables

 Article Access Statistics
    PDF Downloaded467    
    Comments [Add]    
    Cited by others 14    

Recommend this journal