ENDOSCOPIC ULTRASOUND-GUIDED BILIARY DRAINAGE FOLLOWING FAILED ERCP: EXPERIENCE FROM A UK TERTIARY REFERRAL CENTRE 2016-2019

Aims Percutaneous transhepatic biliary drainage (PTBD) is associated with significant morbidity and prolonged hospital stay [1,2]. Endosonography-guided biliary drainage (EUS-BD) is an alternative to PTBD when endoscopic retrograde pancreatography (ERCP) has failed. The aims of this study were to review the technical success and adverse events with EUS-BD procedures performed at a tertiary care referral centre.

Tab. 1 Failures and complications

Procedure	No. of procedures	Aetiology: Benign/Malignant	Technical success	Failures/Complications
Choledochoduodenostomy (CDD) using lumen-apposing metal stent (LAMS)	56	6/50	98.2%	1 failed: ♣ Patient underwent PTBD Complications: ♣ LAMS migration out of duct in 1 patient 4 weeks later with persistent fistula providing biliary drainage ♣ 2 maldeployments (rescued with FCSEMS through LAMS)
CBD rendezvous	14	14/0	78.6%	3 failed: ♣ 2 patients underwent CDD ♣ 1 patient underwent PTBD Complications: ♣ Bile leak in 1 patient
Hepaticogastrostomy	12	1/11	100%	Complications: ♣ Delayed bleeding from stent insertion site in 1 patient ♣ Cholangitis in 1 patient

Methods A prospectively-collected database of EUS-BD procedures performed from 1st August 2016 to 20th November 2019 was reviewed retrospectively. Recorded variables were technical success, adverse events, length of stay and 30-day all-cause mortality.

Results A total of 82 procedures were performed. 45 patients were male (55%); median age 70 years (range 20-90).

Indications for drainage were pancreatobiliary malignant obstruction (n =55), choledocholithiasis (n=14), other metastatic malignancies (n=7), chronic pancreatitis (n=5) and benign duodenal stricture (n=1).

Reasons for failed ERCP were inaccessible papilla (gastric outlet obstruction; n=29), tumour infiltration of ampulla (n=26), obscured intradiverticular ampulla (n=16) and failure to transverse biliary stricture (n=11).

The route of attempted biliary drainage was choledochoduodenostomy in 56, EUS-guided rendezvous in 14 and hepaticogastrostomy in 12.

The procedures were technically successful in 95.1%. Adverse event (AE) rate was 7.3%. Failures and AEs are detailed in table. Median hospital-stay was 3 days (range 0-120 days). 2 patients died within 30 days, both of multiorgan failure due to pre-existing sepsis non-responsive EUS-BD.

Table

Conclusions This study adds to the existing literature supporting EUS-BD [3-5] as an effective alternative to PTBD after failed ERCP. The rendezvous technique seems less successful in this series. Further prospective randomised studies are needed to compare outcomes for EUS-guided versus percutaneous drainage.