Endoscopic Ultrasound-Guided Antegrade Stenting as an Effective Alternative to Endoscopic Retrograde Colangio-Pancreatography-Based Biliary Drainage in the Management of Extra-Hepatic Malignant Biliary Obstruction: Current Perspectives and Limitations

Trans-papillary biliary stenting under Endoscopic Retrograde Colangio-Pancreatography (ERCP) is the standard of care for the management of malignant biliary obstruction, providing biliary decompression and symptomatic relief. However, the success rate is reported to be hindered in up to 10% of cases, typically due to difficult selective biliary cannulation, surgically altered anatomy, gastro-duodenal obstruction, or duodenal stenosis. In such cases, surgical by-pass and Percutaneous Trans-Hepatic Biliary Drainage (PTBD) represent the conventional alternative rescue approaches. Nevertheless, these procedures are associated with high morbidity and a significantly reduced quality of life during the post-operative period. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) has recently been developed and reported as a novel reliable alternative biliary drainage procedure for cases in which ERCP is unsuccessful. In several EUS-BD techniques, EUS-Guided Antegrade Stenting (EUS-AGS) has been proposed as a useful approach.