This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and SuTab. Hi, I'm Jessica Widmer, the Chief of Endoscopy and Advanced Endoscopy Fellowship Program Director at NYU Long Island. I'll be discussing a series of video tips on EUS-guided intrahepatic drainage. For this video tip, we'll be discussing how to choose your access point. Three to five percent of biliary obstruction cases cannot be managed by conventional ERCP. This most commonly occurs due to ampullary pathology, periampullary diverticuli, surgically altered anatomy, and gastric outlet obstruction. EUS-guided biliary drainage is a well-described alternative technique when conventional ERCP EUS-guided biliary drainage can be obtained in a transgastric approach if there are dilated intrahepatic ducts on cross-sectional imaging. A variety of accessories can be used for biliary access. Typically, either a 19- or 22-gauge FNA needle is used, with an option to use a specialized access needle in an attempt to reduce the risk of wire shearing. Many guide wires are available, and there are descriptions in the literature of using 0.035-inch, 0.025-inch, and 0.019-inch guide wires. They can be either straight or have an angled tip. I typically use a straight 0.5-inch guide wire most commonly. I'll focus on the procedural steps for the first series. First, visualize the biliary system on EUS. Next, access the biliary system with an FNA needle and obtain a cholangiogram. Finally, obtain guide wire access. This is the case of an 87-year-old man who was transferred from an outside hospital with obstructive jaundice due to an ampullary mass with gastric outlet obstruction. Initially, he underwent EUS-guided gastroenterostomy. EUS-guided biliary drainage was postponed to allow for IR-guided paracentesis of a small amount of perihepatic ascites. EUS-guided biliary drainage was then pursued. The EUS scope is initially positioned in the proximal stomach. It's important to note the location of the G-junction to avoid transesophageal drainage, which while described in the literature, can cause mediastinitis. Next, the left lobe of the liver is scanned from left to right in order to identify a dilated biliary radical. It's ideal to find a radical from segment 3 of the liver that traverses the EUS screen from the upper left corner down towards the right corner. This correlates with the segment heading centrally towards the hilum. There should also be approximately 2 cm of liver parenchyma between the radical and the gastric wall. It's important to note the scope position on fluoroscopy prior to puncture, being sure to avoid severe angulation that could preclude advancement of accessories and successful stent deployment. ColorFlo Doppler is used to identify regional vasculature prior to puncture. Once a satisfactory position is found, a 19-gauge access needle is advanced into the targeted biliary radical. Bile is aspirated to confirm location and a cholangiogram is then performed. Here you can see that the intrahepatic ducts are dilated. A guide wire is then advanced through the FNA needle and into the biliary system. It's important not to continuously redirect your wire, which can result in shearing of the wire's plastic coating. Let's review some take-home points. Make all attempts to access the liver below the GE junction due to the risk of mediastinitis with transesophageal access. Locate a dilated radical of segment 3 that courses through the hilum. It should be about 2-3 cm within the liver. Check your scope position on fluoroscopy to ensure that the scope is not sharply angulated, which could preclude passage of accessories and successful stent deployment. Take your time. Make sure you're happy with your position. Once the bile duct is punctured, aspirate bile and confirm access with cholangiogram. As the wire is advanced, minimize attempts at redirection through the needle, which causes stripping of the wire's plastic coating. We'd like to invite you to watch the second session of this video tip, which reviews anterograde and transhepatic stenting. Thank you.

EUS-guided intrahepatic drainage

biliary obstruction

FNA needle

cholangiogram

stenting techniques