Long-term outcomes and reinterventions in EUS-guided biliary drainage for malignant biliary obstruction

Background: EUS-guided biliary drainage (EUS-BD) has been increasingly reported as salvage therapy in failed ERCP cases, but its long-term outcomes are unknown. Methods: Long-term outcomes and reinterventions for stent dysfunction and complications were retrospectively studied in patients undergoing EUS-BD for unresectable malignant biliary obstruction.Results: EUS-BD using covered metallic stent (CMS) was performed in 29 patients: 22 hepatico-gastrostomy (HGS) and 7 choledocho-duodenostomy (CDS). Primary cancer was pancreatic in 59%. Six patients (21%) developed early complications: stent misplacement in the peritoneum treated by tandem HGS placement, migration treated by stent-in-stent, 2 cholangitis due to kinking treated by stent-in-stent and PTBD, cholecystitis treated by PTGBA, and bleeding. Eight patients (28%) developed late complications: 5 HGS dysfunction and 3 CDS dislocation. Median time to dysfunction was 129days. Dysfunction due to sludge/food impaction in HGS was treated by balloon cleaning followed by PS placement via HGS in one and trimming of long HGS stent by APC, followed by antegrade CMS placement in distal CBD in the other. Three hyperplasia at uncovered portion of HGS was treated by stent-in-stent PS placement. Three cholangitis due to CDS dislocation was treated either by a new CDS placement, balloon cleaning alone via choledochoduodenal fistula, or transpapillary stenting.Conclusion: Stent dysfunction in EUS-BD was not rare, but reinterventions via EUS-BD route was technically feasible using an ERCP technique.