Prospective evaluation of simplified algorithm for EUS-guided intra-hepatic biliary access and anterograde interventions for failed ERCP.

BACKGROUND: EUS-guided biliary drainage (EUS-BD) is technically challenging but alternative method of therapeutic intervention when ERCP fails. OBJECTIVE: Assess the feasibility, safety and risks of EUS-BD with intra-hepatic biliary access and anterograde interventions using an algorithm to increase flexibility of interventions, limit adverse events and improve procedural time. DESIGN: Prospective observational cohort study. PATIENTS: 21 consecutive patients underwent EUS-BD drainage for failed ERCP. MAIN OUTCOME MEASURES: Technical and clinical success rates with adverse event rate using simplified algorithm. RESULTS: Patient recruitment from June 2011-October 2013; mean age of 67.4 years, predominantly male (70.5 %) with pancreatic cancer (52.4 %), cholangiocarcinoma (14.3 %), other malignant biliary obstruction (9.5 %) and benign biliary obstruction (23.8 %). Prior interventions included failed ERCP in 18/21 (85.7 %) while 3/21 (14.3 %) had primary EUS-BD. Anterograde cholangiogram was achieved in all patients. Technical success was achieved in 20/21 (95.2 %) with clinical success was achieved in 19/21 (90.4 %). Placement of access wire was across the ampulla in 10/20 (50 %) and into CBD or contra-lateral IHD in 10/20 (50 %). Tract dilatation was accomplished in 17/20 (85 %) but required completion using intra-hepatic needle knife in 3/20 (15 %). Anterograde interventions were performed in 16/20 (80 %) but crossover to rendezvous in 3/20 (15 %) or choledochoduodenostomy 1/20 (5 %). Three patients 3/21 (14.3 %) also had endoscopic duodenal SEMS placement to relieve duodenal obstruction. Two patients (9.5 %) had post-procedural bile leak and pain. CONCLUSION: EUS-guided anterograde biliary drainage using the intra-hepatic access route has high technical and clinical success with low adverse rate. We would promote a simplified standardized algorithm, which gives flexibility of direct anterograde interventions.