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 Table of Contents  
Year : 2019  |  Volume : 8  |  Issue : 7  |  Page : 50-56

Drainage of the right liver using EUS guidance

1 Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
2 Surgery Unit, Paoli Calmettes Institute, Marseille, France

Date of Submission30-Jun-2019
Date of Acceptance08-Jul-2019
Date of Web Publication28-Nov-2019

Correspondence Address:
Dr. Fabrice Caillol
Endoscopy Unit, Paoli Calmettes Institute, 232 bd Ste Marguerite, 13009 Marseille
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_52_19

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Hepaticogastrostomy (HGS) has been reported for the management of palliative malignant hilar stricture and involves draining the left liver as rescue therapy. For the management of this complex stenosis, another new option for draining the right liver under EUS guidance was introduced. Ten publications involving 38 patients have been reported in the literature, in which the following two main techniques have been described: direct puncture of the right liver from the bulbus and the bridge technique allowing the drainage of the right liver across the left liver through HGS. In this review, we describe the techniques used and the potential advantages and complications of these procedures. Although this kind of drainage is demanding and probably limited to specific patients, EUS-biliary drainage of the right liver seems feasible with acceptable complications.

Keywords: EUS biliary drainage, liver, review, right liver endoscopic drainage

How to cite this article:
Caillol F, Rouy M, Pesenti C, Ratone JP, Giovannini M. Drainage of the right liver using EUS guidance. Endosc Ultrasound 2019;8, Suppl S1:50-6

How to cite this URL:
Caillol F, Rouy M, Pesenti C, Ratone JP, Giovannini M. Drainage of the right liver using EUS guidance. Endosc Ultrasound [serial online] 2019 [cited 2020 Jul 13];8, Suppl S1:50-6. Available from: http://www.eusjournal.com/text.asp?2019/8/7/50/271812

  Introduction Top

Since the first publication of EUS-biliary drainage (EUS-BD) of the left liver,[1],[2] hepaticogastrostomy (HGS) has become a rescue treatment option for ERCP drainage failure.[3],[4] A recent systemic review with meta-analysis compared EUS-BD and percutaneous transhepatic drainage (PCTD) in 483 patients with malignant biliary obstruction from nine studies and found that despite similar technical success rates, EUS-BD was associated with better clinical success, fewer adverse events, and lower reintervention rates, and overall, it was more cost-effective than PCTD.[5] Recently, HGS as first-line drainage option before ERCP has also been discussed.[6],[7]

Similarly, HGS has been used in the palliative management of malignant hilar stricture. The first publication in 2007, with four patients, described drainage of the left liver under EUS guidance because of a previous stent in the right lobe. Thereafter, a few articles have described HGS as a rescue treatment for hilar stricture with the undrained left liver.[3],[8] In managing complex stenoses, another new option for draining the right liver, which is considered as inaccessible under EUS guidance, was introduced. We herein describe the different liver drainage techniques and results of EUS-BD.

  Literature Search Top

All articles about the drainage of the right intrahepatic bile duct (IHBD) under EUS guidance found in PubMed were included. We only excluded one article, because puncture of the IHBD was not a choice but was required because of altered anatomy due to Ivor-Lewis surgery.[9] Interestingly, these two case series showed the possibility of draining the right liver in the jejunum if the liver is accessible and if the left liver is not visible because of altered anatomy.

All studies had a retrospectives design with a small number of patients. The mean number of patients was 4.2, with a minimum of one patient. The most important series comprised 12 patients. Ten articles by seven different teams with 38 patients were found.

  Techniques Of Right Liver Drainage Under EUS Guidance Top

Two main techniques have been described in the literature. The first technique, described by Park et al.,[10] is EUS-BD, involving direct puncture of the right liver with transluminal stenting between the right hepatic duct and duodenal wall as anterograde bypass stenting. The second technique is the bridge technique, involving the placement of a stent between the right and left livers, which are both drained during HGS, as described by Ogura et al.[11],[12]

  Direct Puncture Of The Right Liver And Hepaticoduodenostomy Top

The puncture is made through the bulbus with a therapeutic echoendoscope in a U-shaped, long endoscope position [Figure 1], [Figure 2], [Figure 3] and [Table 1] and [Table 2]. The puncture must be made with a 19G needle if the goal is to insert a wire, or it has to be made with a 22G needle to insert a 0.021-inch wire before exchanging it with a 0.0025-inch wire, according to Mukai et al.[13]
Figure 1: Hilar stenosis before drainage

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Figure 2: U-shaped position before hepaticoduodenostomy

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Figure 3: Plastic stent placed with hepaticoduodenostomy

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Table 1: Direct puncture of the right liver and transluminal drainage in 13 patients who underwent hepaticoduodenostomy

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Table 2: Materials used for hepaticoduodenostomy

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In the case of transluminal stenting, the right anterior lobe was punctured in four (31%) patients[10],[14],[15] and the posterior lobe, in three (23%) patients.[15],[16] There were no data for six (46%) patients.

  Bridge Technique Top

The liver segment II or III is punctured with a 19G access needle with a therapeutic echoendoscope [Figure 1] and [Figure 4], [Table 3] and [Table 4]. After opacification, a guide wire is introduced into the left bile duct. Then, a fistula is created with a 6-French (Fr) cystotome or dilated with a 7-Fr catheter. By pushing the cystotome or catheter against the hilar stenosis, the guide wire can be inserted into the right liver, usually in the posterior portion. Hilar stenosis between the left and right livers is seen in most cases enlarged with a 4-mm dilation balloon. Next, an uncovered 6 cm long stent is inserted between the right and left livers, creating a bridge between the two organs. Another stent (covered or partially covered) is finally placed between the liver and stomach or jejunum for HGS or hepaticojejunostomy.
Figure 4: Metallic stent between the right liver and left liver: Bridge technique associated with hepaticogastrostomy

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Table 3: Bridge technique in 25 patients

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Table 4: Materials used for the bridge technique

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  Anterograde Technique Without Hepaticoduodenostomy Top

The rendezvous technique has also been described in one patient.[12] In the study by Park et al., a stent was placed using the anterograde technique across the area of stenosis in one case, only an anterograde balloon dilation was placed for benign stricture in 1 case, and the roadmap technique was used in one case.[10] In the absence of transluminal stenting, the anterior lobe was punctured in two cases and posterior lobe, in two cases (including a case of EUS-BD failure); data were lacking in one case.

  Roadmap Technique Top

Only one case in which the roadmap technique was used has been described. The puncture must be made with a 22G needle to perform the roadmap technique in the right posterior lobe,[10] and the cholangiogram obtained by EUS-guided transduodenal puncture of the right hepatic duct is used as a roadmap. ERCP is performed after opacification of the targeted segment for drainage.

  Rendezvous Technique Top

There was only one case in which the rendezvous technique has been described. The puncture in the right IHBD was made with a 19G needle (Sono Tip ProControl; Medi-Globe, Rosenheim, Germany) near the hepatic hilum. A guide wire was inserted into the common bile duct across the stricture (0.025-inch, angle-type, VisiGlide; Olympus Medical Systems, Tokyo, Japan). Then, dilation with an 8-mm balloon catheter was performed (Hurricane balloon catheter; Boston Scientific Japan, Tokyo, Japan). Subsequently, the catheter for ERCP was exchanged, and the guide wire was used as a landmark.[12]

  Balloon Dilation And Placement Of a Stent Top

Two cases of EUS-guided anterograde transanastomotic balloon dilation with or without stenting have been described:[10] one case of balloon dilation alone for benign stricture in altered anatomy and one case of placement of a stent in an anterograde path. In the first case, balloon dilation was performed with a 4-mm dilation balloon, and in the second case, an uncovered metal stent was placed through the echoendoscope across the stricture after dilation.

Given the small number of cases, cases in which the anterograde, roadmap, and rendezvous techniques were used could be considered as clinical cases; thus, we excluded them from the results [Table 1].

  Indications Top

In the case of hepaticoduodenostomy (HDS) (13 patients), the indication of EUS-BD was ERCP failure in 11 (85%) patients, duodenal obstruction in one (8%) patient, and altered anatomy in one (8%) patient. In the case of the bridge technique (25 patients), the indication of EUS-BD was duodenal obstruction in 11 (44%), altered anatomy in eight (32%), and unknown in six (24%) patients. In the study by Poincloux et al., direct puncture of the right IHBD was performed in the case of left hepatectomy and altered anatomy in two cases.[4] Stenosis was benign in three cases (strictures at the site of anastomosis).[10]

  Advantages And Complications Top


Thirteen patients have undergone HDS [Table 1] and [Table 3]. The bridge technique was used in 25 patients, and drainage of the right liver under EUS guidance was performed in 46 patients, with four drainage failures. Only one case of failure of HDS drainage was reported by Park et al.[10] Moryoussef et al. reported a success rate of 50% (3 successes from 6 attempts) for the bridge technique.[18] The size of the IHBD in HDS has been reported in only one study[10] with consequent dilation of the IHBD at approximately 7.8 mm (range, 7.7–11 mm).


A few complications have been reported. Four minor complications (pain managed conservatively)[19] and one case of clinical failure with mortality due to a Bismuth IV tumor were reported[19] with the bridge technique. Thus, the global morbidity rates are 16% for the bridging technique and 9% for all cases of drainage of the right liver under EUS guidance. Survival has been reported for seven patients with HDS (mean 227 days; range, 88–767 days).


The advantage of this kind of procedure must be evaluated in comparison to that of percutaneous drainage. It is important to perform drainage in these patients to improve survival regardless of the technique used. However, external drainage may not improve patient survival.[20] In complex drainage cases, the risk associated with an external drain increases in cases of percutaneous drainage. As a result, HDS can be advantageous in that a previous stent is placed. In the case of altered anatomy or duodenal obstruction, the bridge technique could avoid temporary external drainage.

  Discussion Top

The bridge technique has the following potential complications: Bile leak, stent migration, and cholangitis. Stent dysfunction related to the bridge stent is particularly concerning because of the sharp angle encountered during stent delivery. Therefore, with this stent, it could be challenging to insert the wire into the right IHBD and to place the stent. Ogura et al.[15] recommended the use of a controllable ERCP catheter, fine stent G, and effective delivery system, if necessary. They also strongly advised placing an uncovered stent in the bridge technique to avoid occluding the side branch duct.

In HDS, visualization of the right IHBD can be difficult. It can also be difficult to puncture the right IHBD because it may not be immediately adjacent to the duodenal wall, and the portal vein could be close to the route of the approach. Moreover, the puncture can be difficult because of the position of the endoscope, as sufficient dilation of the right bile duct is needed. Park et al.[10] suggested sufficient IHBD dilation (7.8 mm [range, 7.7–11 mm] in their study) and being as close as possible to the IHBD to facilitate this type of drainage. The authors placed the echoendoscope in a U-shaped position and perform gentle rotation under radiography for better and closer visualization of the right IHBD.

These demanding BD methods are preformed instead of percutaneous transhepatic BD, a drainage technique described before EUS-BD and considered as salvage therapy in the case of ERCP failure according to some publications. However, PCTD is also associated with the following complications: Cholangitis, bile leak, and pneumothorax. The frequency of major complications, such as prolonged hospital stay and permanent adverse sequelae, ranges from 4.6% to 25%.[21],[22] Although this review cannot conclude the superiority of EUS-BD of the right liver over PCTD, it highlights the feasibility of this technique.

This review has a couple of limitations. First, complications and clinical success are not always reported, and all studies had noncomparative retrospective designs; thus, it is difficult to get a precise idea of the complications. Second, EUS-BD for right IHBD can be challenging because the usual puncture site under EUS is the left IHBD or common bile duct. The feasibility of puncturing the posterior or anterior lobe should be discussed.

  Conclusions Top

In the case of HDS or the bridge technique, it may be very challenging to choose the anterior or posterior part of the right liver. These procedures should be selected under strict criteria, such as in patients with a limited prognosis who may not be suitable because they have benign disease.[14]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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. 1
Giovannini M, Dotti M, Bories E, et al. Hepaticogastrostomy by echo-endoscopy as a palliative treatment in a patient with metastatic biliary obstruction. Endoscopy 2003;35:1076-8.  Back to cited text no. 2
Bories E, Pesenti C, Caillol F, et al. Transgastric endoscopic ultrasonography-guided biliary drainage: Results of a pilot study. Endoscopy 2007;39:287-91.  Back to cited text no. 3
Poincloux L, Rouquette O, Buc E, et al. Endoscopic ultrasound-guided biliary drainage after failed ERCP: Cumulative experience of 101 procedures at a single center. Endoscopy 2015;47:794-801.  Back to cited text no. 4
Sharaiha RZ, Khan MA, Kamal F, et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: A systematic review and meta-analysis. Gastrointest Endosc 2017;85:904-14.  Back to cited text no. 5
Paik WH, Lee TH, Park DH, et al. EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: A multicenter randomized clinical trial. Am J Gastroenterol 2018;113:987-97.  Back to cited text no. 6
Bang JY, Navaneethan U, Hasan M, et al. Stent placement by EUS or ERCP for primary biliary decompression in pancreatic cancer: A randomized trial (with videos). Gastrointest Endosc 2018;88:9-17.  Back to cited text no. 7
Nakai Y, Kogure H, Isayama H, et al. Endoscopic ultrasound-guided biliary drainage for unresectable hilar malignant biliary obstruction. Clin Endosc 2019;52:220-5.  Back to cited text no. 8
Poincloux L, Hordonneau C, Rouquette O. Transdiaphragmatic endoscopic ultrasound-guided right hepaticogastrostomy for biliary drainage after Ivor-Lewis esophagectomy. Endoscopy 2016;48 Suppl 1:E201-2.  Back to cited text no. 9
Park SJ, Choi JH, Park DH, et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc 2013;78:374-80.  Back to cited text no. 10
Ogura T, Masuda D, Imoto A, et al. EUS-guided hepaticogastrostomy for hepatic hilar obstruction. Endoscopy 2014;46 Suppl 1:E32-3.  Back to cited text no. 11
Ogura T, Oda S, Sano T, et al. EUS-guided anterograde balloon dilation from right hepatic duct combined with retrograde rendezvous stent placement. Gastroenterology 2015;148:901-3.  Back to cited text no. 12
Mukai S, Itoi T, Tsuchiya T, et al. EUS-guided right hepatic bile duct drainage in complicated hilar stricture. Gastrointest Endosc 2017;85:256-7.  Back to cited text no. 13
Minaga K, Takenaka M, Miyata T, et al. Achievement of long-term stent patency in endoscopic ultrasonography-guided right bile duct drainage after left hepatic lobectomy (with video). Endosc Ultrasound 2017;6:412-3.  Back to cited text no. 14
Ogura T, Sano T, Onda S, et al. Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: Novel technical tips. Endoscopy 2015;47:72-5.  Back to cited text no. 15
Minaga K, Takenaka M, Kitano M, et al. Rescue EUS-guided intrahepatic biliary drainage for malignant hilar biliary stricture after failed transpapillary re-intervention. Surg Endosc 2017;31:4764-72.  Back to cited text no. 16
Ogura T, Onda S, Takagi W, et al. Clinical utility of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention procedure for high-grade hilar stricture. J Gastroenterol Hepatol 2017;32:163-8.   Back to cited text no. 17
Moryoussef F, Sportes A, Leblanc S, et al. Is EUS-guided drainage a suitable alternative technique in case of proximal biliary obstruction? Therap Adv Gastroenterol 2017;10:537-44.  Back to cited text no. 18
Caillol F, Bosshardt C, Reimao S, et al. Drainage of the right liver under EUS guidance: A bridge technique allowing drainage of the right liver through the left liver into the stomach or jejunum. Endosc Ultrasound 2019;8:199-203.  Back to cited text no. 19
Caillol F, Bories E, Zemmour C, et al. Palliative endoscopic drainage of malignant stenosis of biliary confluence: Efficiency of multiple drainage approach to drain a maximum of liver segments. United European Gastroenterol J 2019;7:52-9.  Back to cited text no. 20
Carrasco CH, Zornoza J, Bechtel WJ. Malignant biliary obstruction: Complications of percutaneous biliary drainage. Radiology 1984;152:343-6.  Back to cited text no. 21
Günther RW, Schilid H, Thelen M. Review article: Percutaneous transhepatic biliary drainage: Experience with 311 procedures. Cardiovasc Interv Radiol 1984;11:65-71.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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


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