title: EUS-guided biliary drainage after failed ERCP: a novel algorithm individualized based on patient anatomy.
abstract: OBJECTIVE
  EUS-guided biliary drainage (EUS-BD) has been offered for more than a decade as an alternative to percutaneous biliary drainage. Multiple approaches have been described. We propose an algorithm for biliary drainage based on patient anatomy. We aim to assess its validity and safety to guide EUS-BD drainage.
  
  
  METHODS
  All patients with biliary obstruction who underwent EUS-BD after failed ERCP from July 2011 through November 2015 underwent the drainage procedure according to the novel algorithm and were enrolled in a dedicated prospective registry. Patients with a dilated intrahepatic biliary tree (IHBT) on cross-sectional imaging received an intrahepatic (IH) approach with anterograde biliary stent placement or hepaticogastrostomy stent placement if anterograde placement was not feasible. Patients with a nondilated IHBT on cross-sectional imaging underwent an extrahepatic (EH) approach with a rendezvous (RDV) technique or a transenteric stent placement if the RDV technique was not feasible. If IH drainage was attempted but unsuccessful, conversion to an EH approach was performed.
  
  
  RESULTS
  Fifty-two patients (mean age, 68 ± 12 years; 52% men) were included in the registry. Technical success was achieved in 50 patients (96%). Twenty-seven of 52 patients (52%) underwent IH anterograde stent placement, 8 of 52 (15%) underwent hepaticogastrostomy, 11 of 52 (21%) underwent EH drainage with the RDV technique, and 6 of 52 (12%) underwent EH drainage with transenteric stent placement. Adverse events were observed in 5 patients (10%) and included a liver abscess requiring percutaneous drainage (n = 1) and bleeding (n = 4) with 1 postprocedural death secondary to bleeding.
  
  
  CONCLUSIONS
  EUS-BD obstruction after failed conventional ERCP is successful and safe when this novel algorithm is used. (Clinical trial registration number: NCT01438385.).
authors.affiliation: Division of Gastroenterology & Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Amy
authors.initials: A
authors.lastname: Tyberg
authors.affiliation: Division of Gastroenterology & Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Amit P
authors.initials: AP
authors.lastname: Desai
authors.affiliation: Division of Gastroenterology & Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Nikhil A
authors.initials: NA
authors.lastname: Kumta
authors.affiliation: Division of Gastroenterology & Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Brown
authors.affiliation: Division of Gastroenterology & Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Monica
authors.initials: M
authors.lastname: Gaidhane
authors.affiliation: Division of Gastroenterology & Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Reem Z
authors.initials: RZ
authors.lastname: Sharaiha
authors.affiliation: Division of Gastroenterology & Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Michel
authors.initials: M
authors.lastname: Kahaleh
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000714:Anastomosis, Surgical; D001653:Bile Ducts, Intrahepatic / Q000473:pathology*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002779:Cholestasis / Q000601:surgery*; D004108:Dilatation, Pathologic / Q000000981:diagnostic imaging; D004322:Drainage / Q000379:methods*; D019160:Endosonography; D005260:Female; D006500:Hepatic Duct, Common / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019233:Retreatment; D015607:Stents; D013270:Stomach / Q000601:surgery*; D017211:Treatment Failure; D018084:Ultrasonography, Interventional