Indications for endoscopic ultrasonography (EUS)-guided biliary intervention: Does EUS always come after failed endoscopic retrograde cholangiopancreatography?

Objectives EUS-guided biliary drainage (EUS-BD), first reported as an alternative to percutaneous transhepatic biliary drainage (PTBD) after failed ERCP, is increasingly reported as a primary procedure without failed ERCP. Our study aims are to evaluate the performance of therapeutic biliary ERCP and to compare the safety and effectiveness of primary EUS-BD with those of ERCP, rescue EUS-BD and PTBD. Methods We retrospectively studied the performance of therapeutic biliary ERCP as well as subsequent rescue PTBD and EUS-BD. Additionally, the indications, safety and technical success of primary EUS-BD were evaluated. Results A total of 520 therapeutic biliary ERCPs with a native papilla between August 2013 and September 2015 were analyzed. We encountered 23 cases with inaccessible papilla and 22 cases with failed cannulation, which were rescued by 21 PTBD, 16 EUS-BD and 2 repeat ERCP. Additionally, 40 primary EUS-BD were performed during the same period due to 10 recurrent cholangitis after transpapillary drainage, 5 outside failed cannulation, 4 altered anatomy, 2 history of ERCP-related adverse events (AEs), 2 technical difficulties in stenting under enteroscopy-assisted ERCP and 17 on study protocol. Technical success and AE rates were 95.6% and 14.5% in ERCP, 90.5% and 33.3% in rescue PTBD, 93.8% and 18.8% in rescue EUS-BD, and 95.0% and 22.5% in primary EUS-BD, respectively. Conclusions Rescue EUS-BD was utilized in 3.1% among all ERCPs. Given the comparable technical success and AE rates of both primary and rescue EUS-BD, primary EUS-BD without failed ERCP can be a treatment option if it provides advantages over ERCP. This article is protected by copyright. All rights reserved.