Comparison of endosonography‐guided vs. percutaneous biliary stenting when papilla is inaccessible for ERCP

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. Aim 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.