J Hepatobiliary Pancreat Sci (2013) 20:7180
DOI 10.1007/s00534-012-0569-8
GUIDELINE
TG13 indications and techniques for biliary drainage
in acute cholangitis (with videos)
Takao Itoi Toshio Tsuyuguchi Tadahiro Takada Steven M. Strasberg Henry A. Pitt
Myung-Hwan Kim Giulio Belli Toshihiko Mayumi Masahiro Yoshida Fumihiko Miura
Markus W. Buchler Dirk J. Gouma O. James Garden Palepu Jagannath Harumi Gomi
Yasuyuki Kimura Ryota Higuchi
Published online: 11 January 2013
Japanese Society of Hepato-Biliary-Pancreatic Surgery and Springer 2013
Abstract The Tokyo Guidelines of 2007 (TG07) descri-
bed the techniques and recommendations of biliary
decompression in patients with acute cholangitis. TG07
recommended that endoscopic transpapillary biliary
drainage should be selected as a first-choice therapy for
acute cholangitis because it is associated with a low mor-
tality rate and shorter duration of hospitalization. However,
TG07 did not include the whole technique of standard
endoscopic transpapillary biliary drainage, for example,
biliary cannulation techniques including contrast medium-
Electronic supplementary material The online version of this
article (doi:10.1007/s00534-012-0569-8) contains supplementary
material, which is available to authorized users.
T. Itoi (&)
Department of Gastroenterology and Hepatology,
Tokyo Medical University, 6-7-1 Nishishinjuku,
Shinjuku-ku, Tokyo 160-0023, Japan
e-mail: itoi@tokyo-med.ac.jp
T. Tsuyuguchi
F. Miura
Department of Medicine and Clinical Oncology, Graduate
School of Medicine, Chiba University, Chiba, Japan
T. Takada
Department of Surgery, Teikyo University School of Medicine,
Tokyo, Japan
S. M. Strasberg
Section of Hepatobiliary and Pancreatic Surgery, Washington
University School of Medicine, St. Louis, USA
H. A. Pitt
Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
M.-H. Kim
Department of Internal Medicine, Asan Medical Center,
University of Ulsan, Seoul, Korea
TG13: Updated Tokyo Guidelines for acute cholangitis
and acute cholecystitis
assisted cannulation, wire-guided cannulation, and treat-
ment of duodenal major papilla using endoscopic papillary
balloon dilation (EPBD). Furthermore, recently single-
or double-balloon enteroscopy-assisted biliary drainage
(BE-BD) and endoscopic ultrasonography-guided biliary
drainage (EUS-BD) have been reported as special tech-
niques for biliary drainage. Nevertheless, the updated
Tokyo Guidelines (TG13) recommends that endoscopic
drainage should be first-choice treatment for biliary
decompression in patients with non-surgically altered
anatomy and suggests that the choice of cannulation tech-
nique or drainage method (endoscopic naso-biliary drain-
age and stenting) depends on the endoscopists preference
but EST should be selected rather than EPBD from the
G. Belli
General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy
T. Mayumi
Department of Emergency and Critical Care Medicine,
Ichinomiya Municipal Hospital, Ichinomiya, Japan
M. Yoshida
Clinical Research Center Kaken Hospital, International
University of Health and Welfare, Ichikawa, Japan
M. W. Buchler
Department of Surgery, University of Heidelberg, Heidelberg,
Germany
D. J. Gouma
Department of Surgery, Academic Medical Center, Amsterdam,
The Netherlands
O. J. Garden
Clinical Surgery, The University of Edinburgh, Edinburgh, UK
P. Jagannath
Department of Surgical Oncology, Lilavati Hospital and
Research Centre, Mumbai, India
123
72
aspect of procedure-related complications. In terms of BE-
BD and EUS-BD, although there are many reports on the
their usefulness, they should be performed by skilled en-
doscopists in high-volume institutes, who are good at ent-
eroscopy or echoendosonography, respectively, because
procedures and devices are not yet established.
Free full-text articles and a mobile application of TG13
are available via http://www.jshbps.jp/en/guideline/tg13.
html.
Keywords Cholangitis
Percutaneous biliary drainage

Endoscopic biliary drainage
Endoscopic cholangio-
pancreatography
Guidelines
Introduction
Acute cholangitis varies in severity, ranging from a mild form
which can be treated by conservative therapy to a severe form
which leads to a life-threatening state, e.g. shock state and
altered sensorium. In particular, the severe form often results in
mortality in the elderly [13]. Biliary drainage, which is the
most essential therapy for acute cholangitis, is divided into
three types, surgical, percutaneous transhepatic, and endo-
scopic drainage. Of these therapies, it is well known that sur-
gical intervention leads to the highest mortality rate [1].
Recently, mortality due to acute cholangitis has decreased due
to development of percutaneous transhepatic cholangial
drainage (PTCD) [4] and endoscopic biliary drainage [5, 6].
Nevertheless, acute cholangitis can still be fatal unless it is
treated in a timely way. The Tokyo Guidelines of 2007 (TG07)
described the fundamental biliary drainage techniques for acute
cholangitis [7]. Subsequently, new biliary drainage techniques
for the therapy of acute cholangitis have been reported. Herein,
we describe the indications and techniques of biliary drainage
for acute cholangitis in the updated Tokyo Guidelines (TG13).
Indications and techniques of biliary drainage
In TG13, biliary drainage is recommended for acute cho-
langitis regardless of degree of severity other than some
H. Gomi
Center for Clinical Infectious Diseases, Jichi Medical University,
Tochigi, Japan
Y. Kimura
Department of Surgical Oncology and Gastroenterological
Surgery, Sapporo Medical University School of Medicine,
Sapporo, Japan
R. Higuchi
Department of Surgery, Institute of Gastroenterology, Tokyo
Womens Medical University, Tokyo, Japan
123
J Hepatobiliary Pancreat Sci (2013) 20:7180
cases of mild acute cholangitis in which antibiotics and
general supportive care are effective.
Q1. What is the most preferable biliary drainage?
endoscopic vs percutaneous vs surgical drainage for
acute cholangitis?
We recommend endoscopic biliary drainage for acute
cholangitis (recommendation 1, level B).
We suggest that percutaneous transhepatic biliary
drainage may be considered as alternative
methods when endoscopic biliary drainage is difficult
(recommendation 2, level C).
Endoscopic drainage should be considered the first-choice
drainage procedure because several studies have described it
as less invasive than other drainage techniques [711].
Percutaneous transhepatic cholangial drainage
(supplement video 1)
Indications
Nowadays, percutaneous transhepatic cholangial drainage
(PTCD), also known as percutaneous transhepatic biliary
drainage (PTBD), has become the second choice of therapy
for acute cholangitis following endoscopic drainage
because of possible complications, including intraperito-
neal hemorrhage and biliary peritonitis, and the need for a
long hospital stay. However, PTCD can still be conducted
in any of the following circumstances: (1) in patients with
an inaccessible papilla due to upper GI tract obstruction, as
in duodenal obstruction or surgically altered anatomy like
Whipple resection or Roux-en-Y anastomosis, in which the
passage of endoscope or endoscopic drainage is thought to
be difficult or impossible; (2) when skilled pancreaticob-
iliary endoscopists are not available in the institution.
Furthermore, even in patients with non-surgically altered
anatomy, PTCD can be salvage therapy when conventional
endoscopic drainage has failed. In general, coagulopathy is
a relative contraindication. However, if there is no other
life-saving method, PTCD would be indicated.
Techniques
Before the prevalence of transabdominal ultrasonography,
needle puncture of the bile duct was conducted under
fluoroscopy [4]. Currently, needle puncture is safely per-
formed under ultrasonography to avoid the intervening
blood vessel [12]. Therefore, in the current PTCD proce-
dure, operators should continuously observe the bile duct
using ultrasonography regardless of the presence of
J Hepatobiliary Pancreat Sci (2013) 20:7180
dilation. The PTCD procedure is performed as follows, and
as previously described [4]. Briefly, at first, ultrasonogra-
phy-guided transhepatic puncture of the intrahepatic bile
duct is conducted using an 18- to 22-G needle. After
confirming backflow of bile, a guidewire is advanced into
the bile duct. Finally, a 7- to 10-Fr catheter is placed in the
bile duct under fluoroscopic control over the guidewire.
Puncture using a small-gauge (22-G) needle is safer in
patients without biliary dilation than with biliary dilation.
According to the Quality Improvement Guidelines pro-
duced by American radiologists, the success rates of
drainage are 86 % in patients with biliary dilation and
63 % in those without biliary dilation [12].
Surgical drainage
Indications
In benign diseases like bile duct stones, surgical drainage is
extremely rare because of the prevalence of endoscopic
drainage or PTCD for the therapy of acute cholangitis.
However, in patients with acute cholangitis due to unre-
sectable neoplasms like cancer of the pancreatic head,
hepaticojejunostomy can be performed as bypass surgery
only in limited patients without severe acute cholangitis. In
particular, when periampullary neoplastic lesions like
cancer of the pancreatic head or ampullary cancer, show
both acute cholangitis and duodenal obstruction, double
bypass surgery, hepaticojejunostomy and gastrojejunos-
tomy, may be a rare choice.
Techniques
Open drainage for decompression of the bile duct is per-
formed as a surgical intervention. When surgical drainage
in critically ill patients with bile duct stones is performed,
prolonged operations should be avoided and simple pro-
cedures, such as T-tube placement without choledocholi-
thotomy, are recommended [13].
Endoscopic biliary drainage
Indications
Endoscopic transpapillary biliary drainage has become the
gold standard technique for acute cholangitis, regardless of
whether the pathology is benign or malignant, because it is a
minimally invasive drainage method [4]. On the other hand,
endoscopic drainage using a standard duodenoscope in pati-
ents with duodenal obstruction and surgically altered anatomy,
like Roux-en-Y anastomosis, seems to be contraindicated.
73
The timing of endoscopic biliary drainage is very
important for the clinical outcome. Khashab et al. [14]
described that delayed (more than 72 h after administration)
and unsuccessful ERCP are associated with worse outcomes
in patients with acute cholangitis. Actually, in TG07, two
thirds of outstanding pancreatobiliary surgeons and endos-
copists supported the use of emergent or early drainage in
patients with moderate or severe cholangitis [15].
Techniques
Biliary cannulation
Biliary cannulation should be conducted in advance of
biliary drainage. Basically, there are two biliary cannula-
tion techniques, namely contrast medium-guided cannula-
tion (standard cannulation) and wire-guided cannulation.
Q2. What technique should be used for biliary
cannulation? Standard cannulation or wire-guided
cannulation?
We suggest that either standard cannulation or wire-guided
cannulation can be considered for bile duct access
(recommendation 2, level B).
Two meta-analyses of a randomized controlled trial (RCT)
on the comparison between standard cannulation and wire-
guided cannulation showed that wire-guided cannulation
was able to increase the successful biliary cannulation rate
and prevent post-ERCP pancreatitis [16, 17]. Recently,
however, two RCTs have shown that there is no statisti-
cally significant difference between standard cannulation
and wire-guided cannulation on the success rate of biliary
cannulation or the prevention rate of post-ERCP pancrea-
titis [18, 19]. Therefore, the choice of techniques for biliary
cannulation is still controversial.
When biliary cannulation using standard cannulation or
wire-guided cannulation techniques fails, precutting, which
means an incision of the papilla enabling the bile duct
orifice to be opened for biliary cannulation, may be per-
formed if an alternative method, like PTCD or surgical
intervention, is not performed. In the main, two types of
precutting methods are used. Needle knife precutting using
needle-type sphincterotome is well known as a basic pre-
cutting method (Fig. 1a). Alternatively, several endosco-
pists prefer pancreatic sphincter precutting using a pull-
type sphincterotome for biliary access (Fig. 1b). The use of
precutting methods depends on the institution and endos-
copist. It is known that precutting is likely to cause serious
complications, such as acute pancreatitis and perforation,
and therefore it should be performed only by skilled
endoscopists [20, 21].
123
74
Fig. 1 Precutting technique. a Needle knife precutting using needle-
type sphincterotome. Bile duct orifice is opened by precutting.
b Schema of pancreatic sphincter precutting. Cutting wire is bowed
toward the bile duct direction
Endoscopic naso-biliary drainage and endoscopic
biliary stenting
Indications
Endoscopic transpapillary biliary drainage is divided into
two types: endoscopic naso-biliary drainage (ENBD) as an
external drainage and endoscopic biliary stenting (EBS) as
an internal drainage. Although, basically, both endoscopic
biliary drainage types can be conducted in all acute
123
J Hepatobiliary Pancreat Sci (2013) 20:7180
cholangitis, they may be contraindicated in patients in
whom the endoscope cannot reach the papilla due to GI
tract obstruction or surgically altered anatomy, or in whom
endoscopic procedures are inadequate because of critical
illness. In particular, ENBD should be avoided in patients
with poor compliance, who may remove the tube, and those
with abnormalities of the nasal cavity causing difficulty in
naso-biliary tube insertion.
In the case of biliary drainage for therapy of acute
cholangitis, skillful endoscopic technique is mandatory
because long and unsuccessful procedures may lead to
serious complications in critical ill patients. Therefore,
endoscopists who perform endoscopic biliary drainage in
these patients, should already have a high success rate of
biliary cannulation including the precutting technique.
Q3. What procedure should be used for endoscopic
biliary drainage? ENBD or EBS?
We suggest that either ENBD or EBS may be considered
for biliary drainage (recommendation 2, level B).
Three comparative studies have shown that there is no
statistically significant difference in technical success,
clinical success, complications and mortality between
ENBD and EBS, although a visual analogue scale was
higher in the ENBD group than in the EBS group
(Table 1) [2224]. In consequence of these results, TG13
suggests that either drainage procedure can be selected
according to the preference of the endoscopist. However,
if ENBD is selected for the treatment of acute cholan-
gitis, we should bear in mind that if the patient has
discomfort from the transnasal tube placement, they are
likely to remove the tube themselves, especially elderly
patients.
One RCT has revealed that biliary drainage is not
mandatory after endoscopic clearance of the common bile
duct in patients with choledocholithiasis-induced cholan-
gitis (level B) [25].
Techniques
ENBD (supplement video 2)
ENBD procedures are described in detail in TG07 [4].
Briefly, after selective biliary cannulation, a 5-Fr to 7-Fr
tube is placed in the bile duct as an external drainage over
the guidewire (Fig. 2a).
EBS (supplement video 3)
EBS procedures is also described in the previous guideline
[4]. In brief, after selective biliary cannulation, a 7- to
J Hepatobiliary Pancreat Sci (2013) 20:7180 75

Table 1 Comparison of results between ENBD and stent placement in acute cholangitis cases
References Method n RCT Technical success (%) Clinical success (%) VAS Adverse events (%) Mortality rate (%)

Lee [22] ENBD 40 100 85100 3.9 (2.7) 5 2.5

Yes p = 0.02
EBS 34 98 8292a 1.8 (2.6) 0 12
Sharma [23] ENBD 74 99 100 0 2.7
Yes N/A
EBS 73 98 100 0 2.7
Park [24] ENBD 41 100 86100b 32 0
No N/A
EBS 39 100 80100b 39 0
ENBD endoscopic naso-biliary drainage, EBS endoscopic biliary stenting, RCT randomized controlled trial, VAS visual analog scale [mean
(SD)], N/A not applicable
a
Including pain, fever, and jaundice
b
Including pain, fever, altered sensorium, hypotension, and renal failure

10-Fr plastic stent is placed in the bile duct as an internal
drainage over the guidewire. There are two different stent
shapes, a straight type with a single flap with a sidehole
(Amsterdam type) (Fig. 2b) or radial flaps without a side-
hole (Tannenbaum type) on both sides, and a double pig-
tail type to prevent inward and outward stent migration.
There is no comparative study between straight type and
pig-tail type stents. Therefore, either stent can be selected
according to the preference of the endoscopist.
Treatment of the major papilla
Endoscopic sphincterotomy (EST)
Indications
EST technique is usually used for stone removal and, at
times, prevention of the occlusion of the pancreatic duct
orifice by placement of a large-bore biliary stent (more than
10-Fr or a self-expandable metal stent).
Q4. Is EST necessary in endoscopic biliary drainage?
We suggest that addition of EST should be determined
according to the patients condition and the operators
skill (recommendation 2, level C).
We suggest that EST followed by stone removal without
biliary drainage can be recommended as an alternative
procedure in patients with choledocholithiasis - induced
acute cholangitis (recommendation 2, level C).
As TG07 described, an additional EST is not necessary in
acute cholangitis as follows: (1) additional EST causes
complications such as hemorrhage [26, 27]; (2) post-EST
hemorrhage is one of the risk factors of acute cholangitis
[20]. In particular, the use of EST in patients with severe
(grade III) disease complicated by coagulopathy should be
avoided. Nevertheless, EST has some advantages as fol-
lows: (1) it provides not only drainage but also clearance of
bile duct stones at a single session in patients with cho-
ledocholithiasis (not complicated by severe cholangitis).
(2) Precutting can allow bile duct access, providing biliary
drainage in patients in whom selective biliary cannulation
is impossible using the standard cannulation technique. In
particular, stone removal in one session can shorten the
hospital stay. Therefore, TG13 suggests that addition of
EST should be determined according to the patients con-
dition and the operators skill.
Techniques
The detail of EST procedures is described in TG07 [4].
Briefly, after selective biliary cannulation with or without a
guidewire, a pull-type sphincterotomy incision is per-
formed below the transverse fold (Fig. 3). When the
transverse fold is not present, the superior margin of the
papilla bulge is used as a landmark to determine the length
of the sphincterotomy (supplement video 4). An electro-
surgical generator with a controlled cutting system
(Endocut mode, ICC200, VIO300, ERBE Elektromedizin
GmbH, Tubingen, Germany) is used for EST; the push-
type is used for EST in patients with Billroth II gastrec-
tomy or Roux-en-Y anastomosis. Only a limited incision is
necessary in EST for drainage purposes using a large-bore
stent, unlike that for stone removal [10]. Endoscopists
should remember that EST may cause acute pancreatitis or
cholangitis, which may become life-threatening when
severe [20].

123
76
Fig. 2 Endoscopic biliary drainage. a Endoscopic naso-biliary
drainage. b Endoscopic biliary stenting. A 7-Fr plastic stent is placed
after performing EST and pus comes from the bile duct
Endoscopic papillary balloon dilation (EPBD)
Indications
The EPBD procedure is usually used instead of EST for
removal of bile duct stones [28]. Until now, there has been
no comparative study on the use of EPBD during biliary
123
J Hepatobiliary Pancreat Sci (2013) 20:7180
Fig. 3 Endoscopic sphincterotomy. A pull-type sphincterotomy
incision was performed below the transverse fold
drainage to treat acute cholangitis due to bile duct stones.
EPBD, like EST, has the advantage of reducing the number
of therapeutic sessions and shortening the hospital stay in
patients with acute cholangitis caused by bile duct stones.
One systematic review revealed that EPBD is statistically
less successful for stone removal, requires higher rates of
mechanical lithotripsy, and carries a higher risk of pan-
creatitis, although it also has statistically significant lower
rates of bleeding [29]. Thus, TG13 suggests that EPBD
appears to be useful for treatment in patients who have
coagulopathy and acute cholangitis caused by a small
stone.
On the other hand, theoretically, since the aim of EPBD
is to preserve the function of the sphincter of Oddi, EPBD
alone without biliary drainage is contraindicated for the
therapy of acute cholangitis. In addition, EPBD should be
avoided in patients with biliary pancreatitis.
Techniques
After selective biliary cannulation, a small balloon up to
8-mm in diameter, depending on the diameters of the bile
duct and the stone, is advanced into the bile duct across the
papilla. Then, the sphincter of Oddi is gradually dilated by
inflation of the balloon until the waist of the balloon dis-
appears. Then, clearance of the bile duct stone is conducted
using a basket catheter and balloon catheter.
Special techniques of endoscopic biliary drainage
Recently, several new techniques of endoscopic biliary
drainage have been developed.
J Hepatobiliary Pancreat Sci (2013) 20:7180 77

Balloon enteroscope-assisted bile duct drainage
Indications
ERCP in patients with surgically altered anatomy can be
challenging. In general, Roux-en-Y anastomosis has been
thought to preclude endoscopic access for ERCP because of
the extensive lengths of the efferent and afferent limbs that
must be traversed to reach the major papilla or hepaticojej-
unostomy site. Recently, single balloon enteroscopy (SBE)
and double balloon enteroscopy (DBE) have enabled suc-
cessful ERCP to be performed in patients with such surgi-
cally altered anatomy. Several investigators have reported
various success rates (40 to 95 %) with adverse events rates
below 5 % (Tables 2, 3) [3042]. However, since this
technique may be unsuccessful and time-consuming, its
indication should be cautiously decided. Although ideal
operators are those who are skilled in both balloon enteros-
copy and ERCP, in some institutions, GI endoscopists
advance an endoscope to the papilla or anastomotic site and
then pancreaticobiliary endoscopists perform ERCP.
Therefore, if the operators are not good at this technique,
therapy using balloon enteroscopy should be avoided.
Tokyo, Japan and long-type DBE: EN-450T5, short-type
DBE: EC-450B15/EI-530B, Fujifilm Co., Ltd., Saitama,
Japan), a sliding tube with a balloon and a balloon con-
troller. The DBE has a balloon at the tip of the endoscope
in addition to the balloon of the overtube. Endoscopes are
advanced to the papilla or anastomotic site using the
pushing and pulling techniques (Fig. 4a, b). An injection
catheter and a tapered catheter are used for initial cannu-
lation. First, 0.0250.035-inch guidewires are inserted into
the bile duct. Finally, 58.5-Fr naso-biliary drainage
catheters and self-expandable metallic stents are placed
into the bile duct for biliary decompression. In cases
requiring an endoscopic sphincterotomy, a sphincterotome
and needle knife are advanced into the bile duct over or
alongside the guidewire. In cases of EPBD, a conventional
dilation catheter is used for the papilla or

Techniques (supplement video 5)

The SBE and DBE balloon system consists of a video

enteroscope (XSIF-Q260Y; Olympus Medical Systems,

Table 2 Outcome of single-balloon enteroscopy-assisted ERCP

References n Technical success Adverse
(1st attempt) (%) events (%)

Itoi [30] 11 72 None

Saleem [31] 56 91 None
Wang [32] 12 90 17
Total 79 89 2.50

Table 3 Outcome of double-balloon enteroscopy-assisted ERCP

(n [ 5)
References n Technical success Adverse
(1st attempt) (%) events (%)

Mehdizadeh [34] 5 40 None

Emmett [35] 14 80 None
Aabakken [36] 13 85 None
Masser [37] 9 67 None
Kuga [38] 6 83 None
Pohl [39] 15 87 None
Shimatani [40] 68 96 5
Tsujino [41] 12 94 17
Itoi [42] 9 67 None Fig. 4 Balloon enteroscope-assisted ERCP. a ERCP in esophagojej-
unostomy with Roux-en-Y patient. b ERCP in hepaticojejunostomy
Total 151 86 3.3
with Roux-en-Y patient

123
78
hepaticojejunostomy site. When selective cannulation is
not possible, a needle knife is used for pre-cutting. A
basket catheter, retrieval balloon catheter, and/or mechan-
ical lithotriptor are used for removal of stones.
Endoscopic ultrasonography-guided bile duct drainage
Indications
Recently, endoscopic ultrasonography (EUS)-guided bili-
ary drainage has been reported as a salvage therapy when
standard endoscopic drainage has failed [4354]. Since the
technique and devices of this procedure are not yet estab-
lished and there is no dedicated device for this procedure, it
should be conducted only in selected patients in whom
standard biliary drainage by means of ERCP or PTCD has
failed or is contraindicated for various reasons like con-
siderable ascites. There are two methods of approach in
EUS-guided biliary drainage: (1) EUS-guided intrahepatic
Fig. 5 EUS-guided biliary approaches. a EUS-guided intrahepatic
bile duct approach. b EUS-guided extrahepatic bile duct approach
123
J Hepatobiliary Pancreat Sci (2013) 20:7180
Table 4 Outcome of endosonography-guided bile duct drainage
Drainage No. of Technical Clinical Complications
cases success (%) success (%) (%)
EUS-guided HES 4 100 100 25
IHBD HGS 50 96 98 16
drainage
HJS 4 75 100 0
EUS-guided CDS 61 95 100 16
EHBD CGS 6 100 100 17
drainage
IHBD intrahepatic bile duct, EHBD extrahepatic bile duct, HES he-
paticoesophagostomy, HGS hepaticogastrostomy, HJS hepaticojejun-
ostomy, CDS choledochoduodenostomy, CGS choledochogastrostomy
bile duct drainage (Fig. 5a) by a transesophageal, trans-
gastric or transjejunal approach; (2) EUS-guided extrahe-
patic bile duct drainage (Fig. 5b) by a transduodenal or
transgastric approach. The choice of drainage route
depends on the presence of a gastric outlet obstruction and
the stricture site of the bile duct. Several published data on
EUS-guided intrahepatic bile duct drainage and extrahe-
patic bile duct drainage show that the success rate is high
(95 %), with 93100 % (intention-to-treat) response rates
(Table 4) [4354]. Most of the reported cases of adverse
events were pneumoperitonitis but there was no serious
adverse event. However, since the procedure is not yet
established, it should be conducted by endoscopists skilled
in both echoendosonography and ERCP.
Techniques [55] (supplement video 6 and video 7)
Theoretically, the intrahepatic bile duct and liver, including
the extrahepatic bile duct does not adhere to the GI tract.
Therefore, there is a possibility of bile leakage during the
procedure; particularly, if the procedure fails, serious bile
peritonitis can occur. A needle knife (Zimmon papillotomy
knife, or Cystotome, Wilson-Cook, Winston-Salem, NC)
catheter using electrocautery (EndoCut ICC200, VIO300D,
ERBE Elektromedizin GmbH, Tubingen, Germany), or a
19-gauge needle (EchoTip, Wilson-Cook), is advanced into
the bile duct under EUS visualization after confirming the
absence of intervening blood vessels to avoid bleeding.
After the stylet is removed, bile is aspirated and then
contrast medium is injected into the gallbladder for cho-
lecystography, then a 450 cm long, 0.025- or 0.035-inch
guidewire is advanced into the outer sheath. If necessary, a
biliary catheter for dilation (Soehendra Biliary Dilator,
Wilson-Cook), papillary balloon dilation catheter (Max-
pass, Olympus Medical Systems), and electrical cautery
needle, are used for dilation of the hepaticoenterostomy
site and choledochoenterostomy site. Finally, a 7-Fr plastic
stent or a self-expandable metal stent are advanced into the
bile duct.
J Hepatobiliary Pancreat Sci (2013) 20:7180
Acknowledgments We are indebted to Professor J. Patrick Barron,
Chairman of the Department of International Medical Communica-
tions at Tokyo Medical University, for his editorial review of the
English manuscript.
Conflict of interest None.
References
1. Reynolds BM, Dargan EL. Acute obstructive cholangitis. A
distinct syndrome. Ann Surg. 1959;150:299303.
2. OConnor MJ, Schwartz ML, McQuarrie DG, Sumer HW. Acute
bacterial cholangitis: an analysis of clinical manifestation. Arch
Surg. 1982;117:43741.
3. Welch JP, Donaldson GA. The urgency of diagnosis and surgical
treatment of acute suppurative cholangitis. Am J Surg. 1976;131:
52732.
4. Takada T, Hanyu F, Kobayashi S, Uchida Y. Percutaneous
transhepatic cholangial drainage: direct approach under fluoro-
scopic control. J Surg Oncol. 1976;8:8397.
5. Nagai N, Toki F, Oi I, Suzuki H, Kozu T. Continuous endoscopic
pancreatocholedochal catheterization. Gastrointest Endosc. 1976;
23:7881.
6. Sohendra N, Reynders-Frederix V. Palliative bile duct drainage.
A new endoscopic method of introducing a transpapillary drain.
Endoscopy. 1980;12:811.
7. Tsuyuguchi T, Takada T, Kawarada Y, Nimura Y, Wada K,
Nagino M, et al. Techniques of biliary drainage for acute
cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg.
2007;14(1):3545. (clinical practice guidelines:CPGs).
8. Lai EC, Mok FP, Tan ES, Lo CM, Fan ST, You KT, et al.
Endoscopic biliary drainage for severe acute cholangitis. N Engl J
Med. 1992;24:15826.
9. Leung JW, Chung SC, Sung JJ, Banez VP, Li AK. Urgent
endoscopic drainage for acute suppurative cholangitis. Lancet.
1989;10:13079.
10. Boender J, Nix GA, de Ridder MA, Dees J, Schutte HE, van
Buuren HF, et al. Endoscopic sphincterotomy and biliary drain-
age in patients with cholangitis due to common bile duct stones.
Am J Gastroenterol. 1995;90:2338.
11. Lau JY, Chung SC, Leung JW, Ling TK, Yung MY, Li AK.
Endoscopic drainage aborts endotoxaemia in acute cholangitis.
Br J Surg. 1996;83:1814.
12. Saad WE, Wallace MJ, Wojak JC, Kundu S, Cardella JF. Quality
improvement guidelines for percutaneous transhepatic cholangi-
ography, biliary drainage, and percutaneous cholecystostomy.
J Vasc Interv Radiol. 2010;21:78995.
13. Saltzstein EC, Peacock JB, Mercer LC. Early operation for acute
biliary tract stone disease. Surgery. 1983;94:7048.
14. Khashab MA, Tariq A, Tariq U, Kim K, Ponor L, Lennon AM,
et al. Delayed and unsuccessful endoscopic retrograde cholangi-
opancreatography are associated with worse outcomes in patients
with acute cholangitis. Clin Gastroenterol Hepatol 2012;10:
115761
15. Nagino M, Takada T, Kawarada Y, Nimura Y, Yamashita Y,
Tsuyuguchi T, et al. Methods and timing of biliary drainage for
acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat
Surg. 2007;14(1):6877. (CPGs)
16. Cheung J, Tsoi KK, Quan WL, Lau JY, Sung JJ. Guidewire
versus conventional contrast cannulation of the common bile duct
for the prevention of post-ERCP pancreatitis: a systematic review
and meta-analysis. Gastrointest Endosc. 2009;70:12119.
79
17. Cennamo V, Fuccio L, Zagari RM, Eusebi LH, Ceroni L, Laterza
L, et al. Can a wire-guided cannulation technique increase bile
duct cannulation rate and prevent post-ERCP pancreatitis?: a
meta-analysis of randomized controlled trials. Am J Gastroen-
terol. 2009;104:234350.
18. Manbu T, Ukita T, Shigoka H, Omuta S, Maetani I. Wire-guided
selective cannulation of the bile duct with a sphincterotome: a
prospective randomized comparative study with standard method.
Scand J Gastroenterol. 2011;46:10915.
19. Kawakami H, Maguchi H, Mukai T, Hayashi T, Sasaki T, Isay-
ama H, et al. A multicenter, prospective, randomized study of
selective bile duct cannulation performed by multiple endosco-
pists: the BIDMEN study. Gastrointest Endosc 2012;75:36272.
20. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME,
Dorsher PJ, et al. Complications of endoscopic biliary sphinc-
terotomy. N Engl J Med. 1996;335:90918.
21. Testoni PA, Mariani A, Giussani A, Vailati C, Masci E, Macarri
G, et al. Risk factors for post-ERCP pancreatitis in high- and low-
volume centers and among expert and non-expert operators: a
prospective multicenter study. Am J Gastroenterol. 2010;105:
175361.
22. Lee DW, Chan AC, Lam YH, Ng EK, Lau JY, Law BK, et al.
Biliary decompression by nasobiliary catheter or biliary stent in
acute suppurative cholangitis: a prospective randomized trial.
Gastrointest Endosc. 2002;56:3615.
23. Sharma BC, Kumar R, Agarwal N, Sarin SK. Endoscopic biliary
drainage by nasobiliary drain or by stent placement in patients
with acute cholangitis. Endoscopy. 2005;37:43943.
24. Park SY, Park CH, Cho SB, Yoon KW, Lee WS, Kim HS, et al.
The safety and effectiveness of endoscopic biliary decompression
by plastic stent placement in acute suppurative cholangitis com-
pared with nasobiliary drainage. Gastrointest Endosc. 2008;68:
107680.
25. Lee JK, Lee SH, Kang BK, Kim JH, Koh MS, Yang CH, et al. Is
it necessary to insert a nasobiliary drainage tube routinely after
endoscopic clearance of the common bile duct in patients with
choledocholithiasis-induced cholangitis? A prospective, ran-
domized trial. Gastrointest Endosc. 2010;71:10510.
26. Sugiyama M, Atomi Y. The benefits of endoscopic nasobiliary
drainage without sphincterotomy for acute cholangitis. Am J
Gastroenterol. 1998;93:20658.
27. Hui CK, Lai KC, Yuen MF, Ng M, Chan CK, Hu W, et al. Does
the addition of endoscopic sphincterotomy to stent insertion
improve drainage of the bile duct in acute suppurative cholan-
gitis? Gastrointest Endosc. 2003;58:5004.
28. Komatsu Y, Kawabe T, Toda N, Ohashi M, Isayama M, Tateishi
K, et al. Endoscopic papillary balloon dilation for the manage-
ment of common bile duct stones: experience of 226 cases.
Endoscopy. 1998;30:127.
29. Weinberg BM, Shindy W, Lo S. Endoscopic balloon sphincter
dilation (sphincteroplasty) versus sphincterotomy for common
bile duct stones. Cochrane Database Syst Rev. 2006;(4):
CD004890.
30. Itoi T, Ishii K, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T, et al.
Single balloon enteroscopy-assisted ERCP in 206 patients with
Billroth II gastrectomy or Roux-en-Y anastomosis (with video).
Am J Gastroenterol. 2010;105:939.
31. Saleem A, Baron TH, Gostout C, Topazian MD, Levy MJ,
Petersen BT, et al. Endoscopic retrograde cholangiopancreatog-
raphy using a single-balloon enteroscope in patients with altered
Roux-en-Y anatomy. Endoscopy. 2010;42:65660.
32. Wang AY, Sauer BG, Behm BW, Ramanath M, Cox DG, Ellen
KL, et al. Single-balloon enteroscopy effectively enables diag-
nostic and therapeutic retrograde cholangiography in patients
with surgically altered anatomy. Gastrointest Endosc. 2010;71:
6419.
123
80
33. Haruta H, Yamamoto H, Mizuta K, Kita Y, Uno T, Egami S, et al.
A case of successful enteroscopic balloon dilation for late anas-
tomotic stricture of choledochoduodenostomy after living donor
liver transplantation. Liver Transpl. 2005;11:160810.
34. Mehdizadeh S, Ross A, Gerson L, Leighton J, Chen A, Schembre
D, et al. What is the learning curve associated with double-bal-
loon enteroscopy? Technical details and early experience in 6
U.S. teriary care centers. Gastrointest Endosc. 2006;64:74050.
35. Emmett DS, Mallat DB. Double-balloon ERCP in patients who
have undergone Roux-en-Y surgery: a case series. Gastrointest
Endosc. 2007;66:103841.
36. Aabakken L, Bretthauer M, Line PD. Double-balloon enteros-
copy for endoscopic retrograde cholangiography in patients with
a Roux-en-Y anastomosis. Endoscopy. 2007;39:106871.
37. Masser C, Lenze F, Bokemeyer M, Ullerich H, Domagk D,
Bruewer M, et al. Double balloon enteroscopy: a useful tool for
diagnostic and therapeutic procedures in the pancreaticobiliary
system. Am J Gastroenterol. 2008;103:894900.
38. Kuga R, Furuya CK Jr, Hondo FY, Ide E, Ishioka S, Sakai P.
ERCP using double-balloon enteroscopy in patients with Roux-
en-Y anatomy. Dig Dis. 2008;26:3305.
39. Pohl J, May A, Aschmoeneit I, Ell C. Double-balloon endoscopy
for retrograde cholangiography in patients with choledochojeju-
nostomy and Roux-en-Y reconstruction [Germany with English
abstract]. Z Gastroenterol. 2009;47:2159.
40. Shimatani M, Matsushita M, Takaoka M, Koyabu M, Ikeura T,
Kato K, et al. Effective shortdouble-balloon enteroscope for
diagnostic and therapeutic ERCP in patients with altered gas-
trointestinal anatomy: a large case series. Endoscopy. 2009;41:
84954.
41. Tsujino T, Yamada A, Isayama H, et al. Experiences of biliary
interventions using short double-balloon enteroscopy in patients
with Roux-en-Y anastomosis or hepaticojejunostomy. Dig En-
dosc. 2010;22:211216.
42. Itoi T, Ishii K, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T, et al.
Long and short type double-balloon enteroscopy-assisted thera-
peutic ERCP for intact papilla in patients with a Roux-en-Y
anastomosis. Surg Endosc. 2011 25:71321.
43. Burmester E, Niehaus J, Leineweber T, Huetteroth T. EUS-cho-
langio-drainage of the bile duct: report of 4 cases. Gastrointest
Endosc. 2003;57:24651.
44. Giovannini M, Dotti M, Bories E, Moutardier V, Pesenti C,
Danisi C, et al. Hepaticogastrostomy by echo-endoscopy as a
123
J Hepatobiliary Pancreat Sci (2013) 20:7180
palliative treatment in a patient with metastatic biliary obstruc-
tion. Endoscopy. 2003;35:10768.
45. Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM,
Yeaton P. Interventional EUS-guided cholangiography: evalua-
tion of a technique in evolution. Gastrointest Endosc. 2006;64:
529.
46. Artifon EL, Chaves DM, Ishioka S, Souza TF, Matuguma SE,
Sakai P. Echoguided hepatico-gastrostomy: a case report. Clinics
(Sao Paulo). 2007;62:799802.
47. Bories E, Pesenti C, Caillol F, Lopes C, Giovannini M. Trans-
gastric endoscopic ultrasonography-guided biliary drainage:
results of a pilot study. Endoscopy. 2007;39:28791.
48. Park do H, Koo JE, Oh J, Lee YH, Moon SH, Lee SS, et al. EUS-
guided biliary drainage with one-step placement of a fully cov-
ered metal stent for malignant biliary obstruction: a prospective
feasibility study. Am J Gastroenterol. 2009;104:216874
49. Horaguchi J, Fujita N, Noda Y, Kobayashi G, Ito K, Obana T,
et al. Endosonography-guided biliary drainage in cases with
difficult transpapillary endoscopic biliary drainage. Dig Endosc.
2009;21:23944.
50. Giovannini M, Moutardier V, Pesenti C, Bories E, Lelong B,
Delpero JR. Endoscopic ultrasound-guided bilioduodenal anas-
tomosis: a new technique for biliary drainage. Endoscopy.
2001;33:898900.
51. Yamao K, Bhatia V, Mizuno N, Sawaki A, Ishikawa H, Tajika M,
et al. EUS-guided choledochoduodenostomy for palliative biliary
drainage in patients with malignant biliary obstruction: results of
long-term follow-up. Endoscopy. 2008;40:3402.
52. Itoi T, Itokawa F, Sofuni A, Kurihara T, Tsuchiya T, Ishii K, et al.
Endoscopic ultrasound-guided choledochoduodenostomy in
patients with failed endoscopic retrograde cholangiopancreatog-
raphy. World J Gastroenterol. 2008;14:607882.
53. Binmoeller KF, Nguyen-Tang T. Endoscopic ultrasound-guided
anterograde cholangiopancreatography. J Hepatobiliary Pancreat
Sci. 2011;18:31931.
54. Hara K, Yamao K, Niwa Y, Sawaki A, Mizuno N, Hijioka S,
et al. Prospective clinical study of EUS-guided choledochoduo-
denostomy for malignant lower biliary tract obstruction. Am J
Gastroenterol. 2011;106:123945.
55. Itoi T, Isayama H, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T,
et al. Stent selection and tips of placement technique of EUS-
guided biliary drainage: trans-duodenal and trans-gastric stenting.
J Hepatobiliary Pancreat Sci. 2011;18:66472.