Table 4

Consensus statements on the optimal management of endoscopic ultrasonography-guided biliary drainage (EUS-BD)

StatementsFinal level of agreementEvidence level
Indications for the procedure
1 EUS-BD is recommended as the procedure of choice for biliary drainage in patients with failed ERCP if expertise is availableAppropriate (8.0)High
2 EUS-BD is an alternative procedure to obtain biliary drainage in patients with altered postoperative anatomy or duodenal stenosis precluding ERCP if expertise is availableAppropriate (8.0)Moderate
Optimal approach for drainage
3 In patients with distal common bile duct obstruction, the transduodenal and transhepatic approaches for EUS-BD are usedAppropriate (8.0)Moderate
4 A transhepatic approach to EUS-BD is recommended for hilar blocksAppropriate (8.0)Low
Pre-drainage evaluation
5 MRCP or CECT is recommended in patients with suspected hilar obstruction prior to the EUS-BD procedureAppropriate (9.0)Very Low
Pre-procedural preparations
6 Antibiotic prophylaxis is recommended before the EUS-BD procedureAppropriate (9.0)Moderate
Procedural considerations
7 A 19-gauge EUS-FNA needle is recommended for duct punctureAppropriate (8.0)Moderate
8 A 0.035 inch or 0.025 inch guidewire with floppy tip should be used to negotiate the bile ductAppropriate (9.0)Low
9 Catheters, balloons or cystotomes are recommended for tract dilation. Tract dilation with a precut papillotome is not recommendedAppropriate (8.0)Low
10 Fully or partially covered metal stents are recommended for transluminal stenting. Uncovered metal stents can be used for antegrade transpapillary stentingAppropriate (8.0)Low
11 The use of metal stents is recommended over plastic stents for EUS-BD to reduce the risk of bile leakAppropriate (8.0))Low
Management of complications
12 Multidisciplinary support including interventional radiologist, surgeons and anaesthesiologist to prevent and manage complications is recommended in centres performing EUS-BDAppropriate (9.0)Very Low
Competency and training
13 Training of EUS-BD should be done at expert centres with facilities and expertise in EUS, ERCP and PTBD.Appropriate (9.0)Very Low
14 Training in EUS-BD should only commence in those endoscopists experienced in EUS-FNA, wire manipulation techniques and biliary stent placementAppropriate (9.0)Low
15 Pig or ex vivo models are suitable for hands-on training on EUS-BD and should be incorporated into the training programme for EUS-BDAppropriate (8.0)Low
  • CECT, contrast-enhanced computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; FNA, fine needle aspiration; MRCP, magnetic resonance cholangiopancreatography; PTBD, percutaneous transhepatic biliary drainage.