Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla.
BACKGROUND
ERCP may be challenging or may fail in certain situations, including postsurgical anatomy, periampullary diverticula, ampullary tumor invasion, and high-grade strictures.


OBJECTIVE
To report a large experience with EUS-guided anterograde cholangiopancreatography (EACP) to facilitate ductal access or perform direct EUS-guided therapy in patients with postsurgical anatomy or failed ERCP.


METHODS
Retrospective cohort study.


METHODS
Tertiary referral center.


METHODS
Ninety-five consecutive patients with failed ERCP or inaccessible papilla over a 4-year period.


METHODS
EACP techniques involved ductal puncture and ductography, followed by either guidewire advancement for rendezvous ERCP in patients with duodenoscope accessible papilla or direct drainage in altered anatomy. For failures, crossover to the alternate EACP technique was performed when appropriate.


METHODS
Technical success rates and complications.


RESULTS
EACP procedures were attempted in 95 of 2566 ERCP procedures (3.7%). EUS-guided cholangiography (n = 70) and pancreatography (n = 25) were successful in 97% and 100%, respectively. EUS-guided rendezvous ERCP was successful in 75% of biliary procedures and in 56% of pancreatic procedures. Direct EUS-guided therapy was successful in 86% and 75% of biliary and pancreatic procedures, respectively. Direct interventions included pancreaticogastrostomy (n = 10), anterograde stent across stricture (n = 10), hepaticogastrostomy (n = 8), and choledochoduodenostomy (n = 1). Ten complications (10.5%) related to EACP or subsequent rendezvous ERCP included pancreatitis (n = 5), hematoma (n = 1), bile leak (n = 1), bacteremia (n = 1), pneumoperitoneum (n = 1), and perforation (n = 1).


CONCLUSIONS
Single-center experience; retrospective study.


CONCLUSIONS
EACP complements ERCP and allows successful pancreaticobiliary therapy in a large proportion of patients with failed ERCP or difficult-to-access papilla.
Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA, USA. shahj@sutterhealth.org
Janak N
JN
Shah
Fernando
F
Marson
Frank
F
Weilert
Yasser M
YM
Bhat
Thai
T
Nguyen-Tang
Richard E
RE
Shaw
Kenneth F
KF
Binmoeller
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000601:surgery; D001652:Bile Ducts / Q000000981:diagnostic imaging / Q000601:surgery*; D002758:Cholangiography / Q000009:adverse effects / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000000981:diagnostic imaging / Q000601:surgery*; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic; D015607:Stents; D013997:Time Factors; D017211:Treatment Failure; D018084:Ultrasonography, Interventional