Endoscopic Techniques for Biliary Drainage

Endoscopic intervention has become the cornerstone for the management of biliary obstruction, offering a minimally invasive alternative to surgical or percutaneous approaches. Endoscopic retrograde cholangiopancreatography (ERCP) remains the first-line modality for ductal cannulation and stent placement in benign and malignant strictures. However, when ERCP fails or is precluded by altered anatomy, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a robust second-line strategy. EUS-BD encompasses transluminal procedures such as choledochoduodenostomy and hepaticogastrostomy, as well as rendezvous and antegrade approaches, enabled by real-time imaging and dedicated devices. The advent of lumen-apposing metal stents has simplified transluminal access, reduced leakage and improved stent patency. Contemporary practice balances technical success rates, clinical outcomes and adverse-event profiles, while striving to extend the benefits of endoscopic drainage to patients with surgically altered anatomy, advanced malignancy or complex strictures. Continuous innovation in echoendoscopes, guidewire technology and stent design underpins a global shift towards endoscopic solutions that enhance patient recovery, quality of life and long-term biliary decompression.

Research from Nature Portfolio

A recent systematic analysis compared first-line biliary drainage with endoscopic ultrasound-guided biliary drainage versus ERCP in patients with distal malignant obstruction. Both modalities achieved high technical and clinical success rates, exceeding 90 per cent, with comparable overall adverse-event rates. Subgroup evaluation in patients without duodenal invasion demonstrated that EUS-guided choledochoduodenostomy matched ERCP in efficacy and safety, highlighting its potential as an alternative primary approach. The study underscored the need for large randomised trials to refine patient selection and to validate long-term outcomes of each technique.

Endoscopic Techniques for Biliary Drainage publication trend

The graph below shows the total number of articles in endoscopic techniques for biliary drainage across all publications each year (not limited to Nature Index journals).

Technical terms

Endoscopic retrograde cholangiopancreatography (ERCP): A procedure using duodenal endoscopy and fluoroscopy to access and drain the biliary tree via the papilla.

Endoscopic ultrasound-guided biliary drainage (EUS-BD): A technique employing ultrasound guidance through the gastrointestinal wall to gain biliary access for drainage.

Lumen-apposing metal stent (LAMS): A fully covered metallic device designed to provide stable transluminal conduits between adjacent organs or ducts.

Choledochoduodenostomy: Creation of a direct anastomosis between the common bile duct and the duodenal lumen under EUS guidance.

Gallbladder drainage (EUS-GBD): Endoscopic creation of a fistula between the gallbladder and gastrointestinal tract to relieve biliary obstruction when the cystic duct is patent.

References

1. Endoscopic ultrasound-guided choledochoduodenostomy using single-step lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-p): a prospective pilot study. Endoscopy (2023).
2. The Success and Safety of Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Gastrointestinal Anatomy. Medical Sciences (2025).
3. Effectiveness of endoscopic ultrasound (EUS)‐guided choledochoduodenostomy vs. EUS‐guided gallbladder drainage for jaundice in patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography: Retrospective, multicenter study (GALLBLADEUS Study). Digestive Endoscopy (2024).
4. EUS-guided biliary drainage versus ERCP for first-line palliation of malignant distal biliary obstruction: A systematic review and meta-analysis. Scientific Reports (2019).