EUS-guided biliary drainage with a fully covered metal stent as a novel route for natural orifice transluminal endoscopic biliary interventions: a pilot study (with videos).

BACKGROUND: EUS-guided biliary drainage (EUS-BD) with the use of a fully covered metal stent can result in a large-diameter fistula between the bile duct and the duodenum or stomach. This sustainable fistula may constitute a new endoscopic route to the bile duct.
OBJECTIVE: To assess the feasibility of performing endoscopic procedures through EUS-guided choledochoduodenostomy or hepaticogastrostomy with a fully covered self-expandable metal stent (FCSEMS).
DESIGN: Observational pilot study.
SETTING: Tertiary-care referral center. PATIENTS: This study involved 3 consecutive patients who underwent EUS-BD with an FCSEMS for biliary decompression.
INTERVENTIONS: One to four weeks after EUS-BD with an FCSEMS, endoscopic procedures for the bile duct were performed through the sinus tract to evaluate and manage intrabiliary lesions. MAIN OUTCOME MEASUREMENTS: Technical success and procedural complications of endoscopic procedures through EUS-BD with an FCSEMS.
RESULTS: Endoscopic procedures were completed through the sinus tract of EUS-BD. Two patients underwent photodynamic therapy for tumor bleeding in the common bile duct and argon plasma coagulation on the biliary intraductal papillary mucinous neoplasm repeatedly under direct visual guidance. In the other patient, photodynamic therapy was performed on the malignant hilar stricture through EUS-guided hepaticogastrostomy with an FCSEMS. LIMITATIONS: Small sample size, pilot study.
CONCLUSIONS: EUS-BD with an FCSEMS may result in a large-diameter sustainable fistula. Endoscopic intervention through this fistula seems to be feasible and useful for the management of intrabiliary lesions.