title: Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video).
abstract: BACKGROUND
  EUS-guided biliary drainage (EUS-BD) was introduced as an effective alternative to percutaneous transhepatic biliary drainage after failed ERCP. However, EUS-BD is technically challenging. The intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure. Therefore, technical advances in guidewire manipulation may be required for EUS-BD.
  
  
  OBJECTIVE
  To evaluate our treatment algorithm for guidewire manipulation protocol for EUS-BD after failed ERCP.
  
  
  METHODS
  Prospective, observational cohort study.
  
  
  METHODS
  A tertiary-care academic center.
  
  
  METHODS
  Forty-five consecutive patients undergoing EUS-BD failed ERCP.
  
  
  METHODS
  Enhanced guidewire manipulation protocol (with a plane parallel to the long axis of the bile duct with an EUS needle tip or a new 0.025-inch guidewire in an extrahepatic approach and intrahepatic bile duct puncture of segment 2 and 4F cannula with guidewire probing in the intrahepatic approach) for rendezvous and antegrade therapy, EUS-BD with transluminal stenting for duodenal invasion, and crossover to another technique if each technique failed.
  
  
  METHODS
  Technical and functional success rates and adverse event rate of the current treatment algorithm for EUS-BD.
  
  
  RESULTS
  The overall technical and functional success rates of EUS-BD in this study were 91% (intention to treat, n = 41/45) and 95% (per protocol, n = 39/41), respectively. Specifically, rendezvous (n = 20) and antegrade therapy (n = 14) were initially feasible in 34 of 45 patients (76%). With our protocol, 25 of 45 patients (56%) were eventually treated with rendezvous and antegrade therapy as a first-line or crossover treatment. EUS-guided biliary drainage with transluminal stenting in patients with duodenal invasion or failed antegrade therapy was feasible in the remaining 20 patients (44%). The overall adverse event rate of EUS-BD was 11%.
  
  
  CONCLUSIONS
  Single-operator, nonrandomized study.
  
  
  CONCLUSIONS
  In this prospective study, our treatment algorithm with an enhanced guidewire manipulation protocol appeared to be technically feasible and effective. Given the favorable success rate and acceptable adverse event rate, this may be considered the standard treatment algorithm for future randomized trials of EUS-BD and percutaneous transhepatic biliary drainage.
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea. dhpark@amc.seoul.kr
authors.forename: Do Hyun
authors.initials: DH
authors.lastname: Park
authors.forename: Seung Uk
authors.initials: SU
authors.lastname: Jeong
authors.forename: Byung Uk
authors.initials: BU
authors.lastname: Lee
authors.forename: Sang Soo
authors.initials: SS
authors.lastname: Lee
authors.forename: Dong-Wan
authors.initials: DW
authors.lastname: Seo
authors.forename: Sung Koo
authors.initials: SK
authors.lastname: Lee
authors.forename: Myung-Hwan
authors.initials: MH
authors.lastname: Kim
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D017734:Bile Ducts, Extrahepatic / Q000473:pathology / Q000601:surgery*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects* / Q000379:methods; D002779:Cholestasis / Q000000981:diagnostic imaging / Q000601:surgery*; D015331:Cohort Studies; D004322:Drainage / Q000379:methods; D019160:Endosonography / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects* / Q000379:methods; D015607:Stents; D016896:Treatment Outcome