title: Comparison of endosonography-guided vs. percutaneous biliary stenting when papilla is inaccessible for ERCP.
abstract: BACKGROUND
  Endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting fails in 5-10% patients of malignant biliary obstruction because papilla is inaccessible. Percutaneous transhepatic biliary drainage (PTBD) is an accepted alternative. Endosonography-guided biliary drainage (EUS-BD) has been described recently.
  
  
  OBJECTIVE
  To compare success rates and complications of EUS-BD and PTBD internal stenting.
  
  
  METHODS
  This retrospective study included failed ERCP in inoperable malignant biliary obstruction due to inaccessible papilla undergoing PTBD or EUS-BD. Percutaneous transhepatic cholangiography guided/EUS-guided rendezvous procedures were excluded. When PTBD internal stenting failed, external drainage was performed. EUS-BD was performed using either intra- or extrahepatic approach, and stents were placed by transmural (choledocho-duodenostomy or hepatico-gastrostomy) or antegrade approach. Self-expandable metallic stents or plastic stents were placed in both groups. Success of internal stenting and complications were compared using t-test and chi-squared test.
  
  
  RESULTS
  Retrospective review of 6 years of records (2005-2011) revealed 50 patients meeting the required criteria. EUS-BD was attempted in 25 and PTBD in 26 patients (one crossover from EUS-BD to PTBD). Internal stenting was technically and clinically successful in 23/25 (92%) EUS-BD vs. 12/26 (46%) PTBD (p < 0.05). External catheter drainage was performed in remaining 14 PTBD patients. Complications occurred in 5/25 (20%) EUS-BD (one major, four minor) and in 12/26 (46%) PTBD (four major, eight minor; p < 0.05). Late stent occlusion occurred in one EUS-BD and three PTBD.
  
  
  CONCLUSIONS
  In this retrospective study comparing success and complications of EUS-BD and PTBD in patients with inoperable malignant biliary obstruction and inaccessible papilla, EUS-BD was found superior to PTBD for both comparators.
authors.affiliation: Deenanath Mangeshkar Hospital and Research Center, Pune, India.
authors.forename: Amol
authors.initials: A
authors.lastname: Bapaye
authors.affiliation: Deenanath Mangeshkar Hospital and Research Center, Pune, India.
authors.forename: Nachiket
authors.initials: N
authors.lastname: Dubale
authors.affiliation: Deenanath Mangeshkar Hospital and Research Center, Pune, India.
authors.forename: Advay
authors.initials: A
authors.lastname: Aher
keywords: EUS; PTBD; biliary drainage; biliary stenting; choledocho-duodenostomy; hepatico-gastrostomy; interventional EUS; therapeutic endosonography