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Page 4 of 6 Armellini et al. Mini-invasive Surg 2018;2:23 I http://dx.doi.org/10.20517/2574-1225.2018.07

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Figure 2. Control CT-scan on (A) axial plane and (B) sagittal reconstruction showing both plastic and metal stents in place

imaging. The authors defined an algorithm based on anatomy more than on the endoscopist’s preference,
so it required good technical experience with respect to different drainage procedures, which could also
be applied in a sequential manner. Notably, they reported a high technical success rate (96%) with a low
rate of adverse events (10%). In accordance with Tyberg’s alghorithm, the first element to be evaluated is
intrahepatic bile ducts dilation. If dilation is noted, anterograde stenting or hepatico-gastric drainage are
suggested. If intrahpeatic ducts are not dilated, a rendezvous-based technique (from the intrahepatic or
extrahepatic tract) is suggested. If this fails, transenteric stenting is still feasible. This interesting algorithm
standardizes the EUS-BD approach for patients with biliary obstruction.

EUS-BD offers some clear advantages over ERCP. First, it does not require papillary cannulation, which
carries out a risk of post-ERCP pancreatitis. Second, it allows creation of an anastomosis at a distance
from the tumor, thus avoiding the risk of ingrowth or overgrowth with consequent stent dysfunction.
Furthermore, EUS-BD can target different sites of the biliary tree, thus allowing drainage also in unfavor-
able situations both for ERCP, such as gastric outlet obstruction or post-surgical anatomy, and for PTBD
[18]
such as ascites or liver lesions . In comparison with PTBD, EUS-BD appears to be faster and more cost-
saving, since the procedure can be performed immediately after ERCP, thus avoiding repeated procedures
and prolonged hospital stays [19-21] . On the other hand, performing this type of biliary recanalization may
hamper endobiliary ablation, a technique used to control endobiliary tumor growth, and this may be a
disadvantage of the EUS-BD technique. However, trans-luminal EUS-guided radiofrequency ablation by
specifically designed active needles (such as EUSRA™ RF Electrode-VIVA RF Generator, STARmed, Seoul,
Korea or Habib™ EUS-RFA catheter, Emcision Ltd., London, UK) is feasible and probably facilitated by the
absence of a standard biliary stent in the tract involved by a pancreatic tumor [22,23] .

In conclusion, even though we are still far from routine use of EUS-BD in common practice, it has been
shown as a feasible and promising alternative to PTBD after failed ERCP. More emphasis on routine use
of these procedures will come from recent development of dedicated accessories in addition to diffusion
among endoscopists of the knowledge and practice of advanced ultrasonographic procedures.

DECLARATIONS
Author’s contributions
Performed the procedure: Armellini E, Ballarè M
Drafted the paper: Armellini E
Edited the movie clip: Mazza F, Donato G
Revised the manuscript for relevant intellectual content: Orsello M, Occhipinti P