Endoscopic ultrasound guided biliary drainage in malignant biliary obstruction and failed ERCP-Initial experience of tertiary Hepato-pancreato-biliary center in Sri Lanka

Introduction: The traditional primary method for treating biliary blockage is endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography and biliary drainage (PTBD). In centers with expertise in Endoscopic ultrasound (EUS), it is increasingly being used to drain obstructed biliary tracts especially in patients with failed ERCP. The biliary tract can be drained to the stomach (Hepatico-gastrostomy-HGS) or duodenum (Choledoco-duodenostomy-CD) with EUS and fluoroscopy guidance using a self-expandable metal stent.
Materials and methods: This is a retrospective descriptive study among 18 patients with malignant biliary obstruction who underwent EUS-BD after failed ERCP from 2019 to 2023 in a tertiary HPB center in Sri Lanka. All procedures were performed by a single gastroenterologist (NF). 
Results: The mean age was 63 years (range 35–78) with the male: female ratio 1: 1. The commonest indications for the procedure was obstructive jaundice with failed ERCP due to failed biliary cannulation (13/18). CD and HGS techniques were performed on nine patients each. CD was performed in patients with distal bile duct obstruction (Pancreatic head cancer n= 7/9) and HGS in patients with proximal bile duct obstruction (Hilar cholangiocarcinoma n=7/9). The technical success was 100% in our experience and the clinical success was 94%. One patient died on day 1 of a myocardial infarction while post-procedure cholangitis was inevitable for all the patients. The success rates and adverse events were comparable between both CD and HGS groups.
Conclusion: EUS-BD is an effective and efficient procedure to achieve biliary drainage in patients with malignant biliary obstruction after ERCP failure with minimal complications.