The Role of Endoscopic Ultrasound Guidance for Biliary and Pancreatic Duct Access and Drainage to Overcome the Limitations of ERCP: a Retrospective Evaluation.

Background Endoscopic ultrasound (EUS)-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure. Methods Consecutive duct access procedures (n=2205; 95% biliary) performed between June 2013 and November 2015 at a tertiary-care center were reviewed. ERCP was used first line, EUS-DAD as salvage after ERCP, and PTBD when both had failed. Procedures were defined as "index" in patients without prior endoscopic duct access and "combined" when EUS-DAD followed successful ERCP. The main outcomes were the EUS-DAD and PTBD rates. Results EUS-DAD was performed in 7.7% (170/2205) of overall procedures: 9.1% (116/1274) index and 5.8% (54/931) follow-up. Most index EUS-DADs were performed following (46%) or anticipating (39%) ERCP failure, whereas 15% followed successful ERCP (combined procedures). Among index procedures, the EUS-DADrate was higher in surgically altered anatomy (58.2% [39/67)] vs. 6.4% [77/1207]); PTBD was required in 0.2% (3/1274). Among follow-up procedures, ERCP represented 85.7%, cholangiopancreatography through mature transmural fistulas 8.5%, and EUS-DAD5.8%; no patient required PTBD. The secondary PTBD rate was 0.1% (3/2205). Six primary PTBDs were performed (overall PTBD rate 0.4% [9/2205]). Conclusions EUS-DAD was required in 7.7% of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1%. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure, and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes the limitations of ERCP eliminating the need for primary and salvage PTBD in most cases.