Vinay Dhir

10.1055/a-2721-6292 In the above-mentioned article the values for “Technical success” and “Clinical success” in Table 3 have been corrected. This was corrected in the online version on December 19, 2025. Article published online: 17 December 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Endoscopic ultrasound-guided biliary drainage (EUS-BD) may be transluminal (choledochoduodenostomy [CDS] and hepaticogastrostomy [HGS]) or transpapillary via an antegrade approach; it is unclear which route is preferred. We conducted a multicenter randomized study comparing the two routes. In this open-label randomized study from five tertiary centers, patients with unresectable malignant biliary obstruction and failed endoscopic retrograde cholangiopancreatography were randomized to either EUS-CDS/HGS or transpapillary stenting. The primary outcome was stent patency (recurrent biliary obstruction), assessed at 1, 3, 6, and 12 months. Analysis was on a per-protocol basis. 120 patients (67 males) were recruited (November 2021 to March 2024), with 60 patients in each arm (24 CDS, 36 HGS). The median time to recurrent biliary obstruction was 294 days (95%CI 257.95–330.04) in the transpapillary group and 219 days (95%CI 122.45–315.54) in the transluminal group (P = 0.03). At 3 months, 11/54 stents (20.4%) were blocked in the transluminal group versus 3/52 (5.8%) in the transpapillary group (odds ratio [OR] 0.24, 95%CI 0.06–0.91; P = 0.04). At 6 months, 21/54 stents (38.9%) were blocked in the transluminal group versus 11/52 (21.2%) in the transpapillary group (OR 0.42, 95%CI 0.18–0.99; P = 0.04). There were 13 (21.7%) adverse events in the transluminal group (one death), and 8 (13.3%) in the transpapillary group (OR 0.57, 95%CI 0.21–1.46; P = 0.33). Transpapillary EUS-BD achieved longer stent patency and a lower rate of recurrent biliary obstruction at 3 and 6 months compared with the transluminal route.

Difficult biliary cannulation (DBC) is a marker for prolonged procedure time and a higher rate of adverse events (AEs) during endoscopic retrograde cholangiopancreatography (ERCP). We previously showed that endoscopic ultrasound-assisted rendezvous (EUS-RV) procedures had a higher single-session success rate than precut papillotomy (PCP) in cases of DBC. The present randomized study aimed to compare the technical success and AE rates of the two approachesThis was an open-label randomized controlled trial in a tertiary care setting. Patients with malignant distal biliary obstruction (MDBO) and DBC were enrolled. The patients were randomized to PCP with a needle-knife or EUS-RV. The primary outcome was technical success; secondary outcomes were the AE rate, procedure duration, and length of hospital stay (LOS).208 patients were enrolled, 104 in each group. There were no statistically significant differences in technical success (93.3% PCP vs. 97.1% EUS-RV; P = 0.33; odds ratio [OR] 0.4, 95%CI 0.1–1.6) and overall AE rate (11.5% PCP vs. 5.8% EUS-RV; P=0.14; OR 0.5, 95%CI 0.8–5.9). Pancreatitis was higher in the PCP group (8.7% vs. 1.9%; P=0.06; OR 4.8, 95%CI 1.0–22.9). The mean duration of the procedure was significantly higher for EUS-RV (47 vs. 27 minutes; P<0.001). LOS was similar in the two groups (1.2 PCP vs. 1.1 days EUS-RV; P=0.25).Both PCP and EUS-RV have comparable rates of success, AEs, mortality, and LOS. EUS-RV could be used as an alternative to PCP in patients with MDBO and DBC.

Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) includes EUS-guided hepaticogastrostomy (EUS-HGS), EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided gallbladder drainage (EUS-GBD), EUS-guided antegrade stenting (EUS-AG) and EUS-guided rendezvous (EUS-RV). While EUS-HGS, EUS-CDS and EUS-GBD are transluminal drainage procedures, EUS-AG is a traspapillary drainage procedure and EUS-RV is a procedure intended to facilitate endoscopic retrograde cholangio pancreatography (ERCP) in instances of failed cannulation. These procedures were initially developed as options for endoscopic salvage of failed ERCP, but have evolved to become first-line interventions also for select indications over time as the technique and expertise improved. Several randomised controlled trials have demonstrated EUS-BD, especially EUS-CDS has similar or even better outcomes as compared to ERCP in malignant biliary obstruction. However, widespread adoption of these modalities is limited by the availability of expertise, steep learning curve, lack of standardization of techniques and cost. In this review, we aim to provide an overview of various EUS-BD procedures including the indications, accessories, technique, outcomes and follow-up of each of these procedures.

Interventional endoscopic ultrasound (IEUS) has gained significant popularity in recent years because of its diagnostic and therapeutic capabilities. The proper training of endoscopists is critical to ensure safe and effective procedures. This review study aims to assess the impact of different training models on the competence of trainees performing IEUS. Eight studies that evaluated simulators for IEUS were identified in the medical literature. Various training models have been used, including the EASIE-R, Mumbai EUS, EUS Magic Box, EndoSim, Thai Association for Gastrointestinal Endoscopy model, and an ex vivo porcine model (HiFi SAM). The trainees underwent traditional didactic lectures, hands-on training using simulators, and direct supervision by experienced endoscopists. The effectiveness of these models has been evaluated based on objective and subjective parameters such as technical proficiency, operative time, diagnostic success, and participant feedback. As expected, the majority of skills were improved after the training sessions concluded, although the risk of bias is high in the absence of external validation. It is difficult to determine the ideal simulator among the existing ones because of the wide variation between them in terms of costs, reusability, design, fidelity of anatomical structures and feedback, and types of procedures performed. There is a need for a standardized approach for the evaluation of IEUS simulators and the ways skills are acquired by trainees, as well as a clearer definition of the key personal attributes necessary for developing a physician into a skilled endoscopist capable of performing basic and advanced therapeutic EUS interventions.

Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined, and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreatography (ERCP). However, even in expert hands, the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or, more commonly, percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreaticobiliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD, and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, however, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories, making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, Society of Gastrointestinal Endoscopy of India (SGEI) deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates.EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized.Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.