Digestive Diseases

July 22, 2025

Therapeutic endoscopic ultrasound (EUS) is a rapidly evolving tool that allows access to and interventions in the biliary and pancreatic ducts, the gallbladder, intra-abdominal fluid collections, and adjacent luminal structures. The introduction of therapeutic channel, linear-array echoendoscopes, equipped with improved image quality, Doppler capabilities and dedicated tools, facilitates the management of a range of benign and malignant conditions of the pancreaticobiliary and luminal gastrointestinal tract.

In an article published in Gastroenterology Clinics of North America in 2024, Mayo Clinic endoscopists provide a detailed review of published data on EUS-guided access and antegrade stenting, direct EUS-guided drainage, and EUS-guided luminal anastomosis.

According to Ryan J. Law, D.O., all of these procedures have only become clinically available in larger numbers in the last 10 to 15 years. Dr. Law, an endoscopist and researcher at Mayo Clinic in Rochester, Minnesota, served as a co-author on the review article.

"Over time, we have identified technical refinements to streamline the procedural steps and mitigate risk," explains Dr. Law.

General considerations for EUS-guided procedures

The co-authors share Mayo Clinic's extensive experience with these procedures, noting that they should be performed by experienced endoscopists and in settings that have fluoroscopy and backup provided by hepatopancreatobiliary surgery and interventional radiology teams.

Because some EUS-guided procedures have a relatively high rate of associated adverse events, careful patient selection, planning and knowledge of salvage options are important. The co-authors note that general contraindications to therapeutic EUS include an inability to tolerate sedation, significant and uncorrectable coagulopathy, large-volume ascites, and intervening vasculature between the EUS transducer and the target.

Below is a brief summary focusing on direct EUS-guided pancreatobiliary drainage. Consult the full review article for detailed, procedure-specific discussions and related videos outlining the following: indications and contraindications, patient preparation, procedural equipment and technical steps, management of adverse events and salvage procedures, clinical outcomes, and follow-up care.

Direct EUS-guided drainage

• Bile duct drainage

  EUS-guided biliary drainage (EUS-BD) is now being used as a second line option for bile duct drainage after failed endoscopic retrograde cholangiopancreatography (ERCP) and as a potential primary therapy for distal malignant bile duct obstruction.

  Techniques for EUS-BD include EUS-guided choledochoduodenostomy (EUS-CDS) and hepaticogastrostomy (EUS-HGS). The approach depends on healthcare professional preference, pathology (benign versus malignant), location (distal versus hilar) and potential for future surgical management.

  A recent meta-analysis has shown that EUS-CDS and EUS-HGS have similar technical and clinical success rates and adverse event rates.

• Gallbladder drainage

  EUS-guided gallbladder drainage (GBD) provides a nonsurgical option for patients requiring gallbladder decompression that overcomes some of the limitations associated with both percutaneous gallbladder drainage (PT-GBD) and endoscopic transpapillary gallbladder drainage (ET-GBD).

  EUS-GBD allows for internal gallbladder drainage and enables the conversion of percutaneous cholecystostomy drains to an internal drainage strategy in patients who are not candidates for cholecystectomy. Additionally, EUS-GBD can be used for the treatment of malignant biliary obstruction when ERCP or EUS-BD is not possible and the cystic duct is patent.

  ET-GBD should be considered when there is significant coagulopathy or antithrombotic medication use, large-volume ascites, or another indication for ERCP such as cholangitis or choledocholithiasis. Cholecystectomy with enterotomy repair is feasible after EUS-GBD, but multidisciplinary discussions should address whether ET-GBD is preferable in such patients.

  Compared with PT-GBD, EUS-GBD has similar technical and clinical success rates and lower adverse event rates, reintervention rates and postprocedural pain scores. Compared with ET-GBD, EUS-GBD has higher clinical and technical success rates, similar adverse events rates, and lower reintervention rates.

• Pancreatic fluid collection drainage

  EUS-guided drainage is the standard of care for symptomatic or infected pancreatic fluid collections, including infected or sterile pancreatic pseudocysts, walled-off necrosis (WON) and postsurgical collections. Mayo Clinic endoscopists consider size, location, amount of solid necrosis and presence of infection when making decisions about the optimal approach.

  Compared with surgical management, EUS-guided management of pseudocysts and WON has good clinical success rates and favorable data related to hospital length of stay and adverse event rates. Adverse event rates for EUS-guided drainage of peripancreatic fluid collection vary by technique and type of stent used.

  EUS-guided drainage of WON is often augmented by percutaneous drainage, particularly when the collections extend inferiorly toward the pelvis. While surgical intervention can be performed for management of such collections, this is uncommon in current practice. If pseudoaneurysms are present, Dr. Law and colleagues request percutaneous vascular intervention to prevent rupture and life-threatening hemorrhage that can arise during endoscopic management of the fluid collection.

Dr. Law explains that additional research is needed to further knowledge and improve patient outcomes for therapeutic ultrasound-guided approaches. "We need to understand which patients are ideal for these procedures and learn more about risk mitigation," says Dr. Law. "Additionally, it is likely that further procedural tools will be commercially available in the near future to streamline the procedural technique."

For more information

Khan R, et al. Therapeutic endoscopic ultrasound and endoscopic ultrasound-endoscopic retrograde cholangiopancreatography interventions. Gastroenterology Clinics of North America. 2024;53:683.

Refer a patient to Mayo Clinic.