title: Prospective evaluation of simplified algorithm for EUS-guided intra-hepatic biliary access and anterograde interventions for failed ERCP.
abstract: BACKGROUND
  EUS-guided biliary drainage (EUS-BD) is technically challenging but alternative method of therapeutic intervention when ERCP fails.
  
  
  OBJECTIVE
  Assess the feasibility, safety and risks of EUS-BD with intra-hepatic biliary access and anterograde interventions using an algorithm to increase flexibility of interventions, limit adverse events and improve procedural time.
  
  
  METHODS
  Prospective observational cohort study.
  
  
  METHODS
  21 consecutive patients underwent EUS-BD drainage for failed ERCP.
  
  
  METHODS
  Technical and clinical success rates with adverse event rate using simplified algorithm.
  
  
  RESULTS
  Patient recruitment from June 2011-October 2013; mean age of 67.4 years, predominantly male (70.5 %) with pancreatic cancer (52.4 %), cholangiocarcinoma (14.3 %), other malignant biliary obstruction (9.5 %) and benign biliary obstruction (23.8 %). Prior interventions included failed ERCP in 18/21 (85.7 %) while 3/21 (14.3 %) had primary EUS-BD. Anterograde cholangiogram was achieved in all patients. Technical success was achieved in 20/21 (95.2 %) with clinical success was achieved in 19/21 (90.4 %). Placement of access wire was across the ampulla in 10/20 (50 %) and into CBD or contra-lateral IHD in 10/20 (50 %). Tract dilatation was accomplished in 17/20 (85 %) but required completion using intra-hepatic needle knife in 3/20 (15 %). Anterograde interventions were performed in 16/20 (80 %) but crossover to rendezvous in 3/20 (15 %) or choledochoduodenostomy 1/20 (5 %). Three patients 3/21 (14.3 %) also had endoscopic duodenal SEMS placement to relieve duodenal obstruction. Two patients (9.5 %) had post-procedural bile leak and pain.
  
  
  CONCLUSIONS
  EUS-guided anterograde biliary drainage using the intra-hepatic access route has high technical and clinical success with low adverse rate. We would promote a simplified standardized algorithm, which gives flexibility of direct anterograde interventions.
authors.affiliation: Department of Gastroenterology, Waikato Hospital, Pembroke Street, Hamilton, 3200, New Zealand, frank.weilert@waikatodhb.health.nz.
authors.forename: Frank
authors.initials: F
authors.lastname: Weilert
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001650:Bile Duct Neoplasms / Q000175:diagnosis / Q000601:surgery; D001653:Bile Ducts, Intrahepatic / Q000601:surgery; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002779:Cholestasis / Q000175:diagnosis / Q000601:surgery; D004322:Drainage / Q000379:methods*; D019160:Endosonography / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000175:diagnosis / Q000601:surgery; D011446:Prospective Studies; D012086:Reoperation; D025321:Surgery, Computer-Assisted / Q000379:methods*; D017211:Treatment Failure