title: Endoscopic ultrasound guided biliary drainage in patients with unapproachable ampullae due to malignant duodenal obstruction.
abstract: OBJECTIVE
  When endoscopic retrograde cholangiopancreatography (ERCP) is not possible due to duodenal obstruction, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternate mode of biliary decompression. This study aims to determine the safety and outcomes of performing EUS-BD in such patients.
  
  
  METHODS
  A retrospective review of our endoscopy procedure database was carried out to identify patients with malignant biliary obstruction and failed ERCP in whom EUS-BD was attempted.
  
  
  RESULTS
  Seven patients were identified. The technical success rate was 6/7 (86%). Four patients were treated with a choledochoduodenostomy; two had hepaticogastrostomies; drainage was not attempted in one due to unfavorable anatomy on EUS. In three patients, EUS-BD was performed immediately after unsuccessful ERCP as a single procedure. The initial choice of stent was plastic in two, self-expanding uncovered metal in two, and fully covered metal in two. The median follow-up was 15.5 weeks. There were no immediate complications. Bilirubin decreased in 5/6 (83%) and jaundice resolved in 4/6 (67%). Pruritus resolved in 4/4 (100%). Chemotherapy was restarted in 4/6 (67%). Reintervention due to stent blockage occurred twice. Both were converted to fully covered metal stents. No instances of stent migration were observed.
  
  
  CONCLUSIONS
  In our series, EUS-BD is a feasible, safe, and effective method of internal drainage in appropriately selected patients with biliary obstruction and unapproachable ampullae due to malignant duodenal obstruction. EUS-BD can be performed immediately after a failed ERCP under the same anesthesia. Covered metal stents may be preferred, but further study is required.
authors.affiliation: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, P.O. Box 273, New York, NY 10065, USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Belletrutti
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: DiMaio
authors.forename: Hans
authors.initials: H
authors.lastname: Gerdes
authors.forename: Mark A
authors.initials: MA
authors.lastname: Schattner
mesh_terms: D000328:Adult; D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde; D004322:Drainage / Q000379:methods*; D004379:Duodenal Neoplasms / Q000150:complications / Q000628:therapy*; D004380:Duodenal Obstruction / Q000209:etiology / Q000628:therapy*; D016099:Endoscopy, Gastrointestinal; D019160:Endosonography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000150:complications / Q000628:therapy*; D011446:Prospective Studies; D012189:Retrospective Studies; D015607:Stents; D015996:Survival Rate; D016896:Treatment Outcome