A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction

What can the Interventional Endoscopist Offer in the Management of Upper Gastrointestinal Malignancies?

The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations.

Endoscopic ultrasound-rendezvous versus percutaneous-endoscopic rendezvous endoscopic retrograde cholangiopancreatography for bile duct access: Systematic review and meta-analysis

OBJECTIVES

Endoscopic ultrasound (EUS) or percutaneous-assisted antegrade guidewire insertion can be used to achieve biliary access when standard endoscopic retrograde cholangiopancreatography (ERCP) fails. We conducted a systematic review and meta-analysis to evaluate and compare the effectiveness and safety of EUS-assisted rendezvous (EUS-RV) and percutaneous rendezvous (PERC-RV) ERCP.

METHODS

We searched multiple databases from inception to September 2022 to identify studies reporting on EUS-RV and PERC-RV in failed ERCP. A random-effects model was used to summarize the pooled rates of technical success and adverse events with 95% confidence interval (CI).

RESULTS

In total, 524 patients (19 studies) and 591 patients (12 studies) were managed by EUS-RV and PERC-RV, respectively. The pooled technical successes were 88.7% (95% CI 84.6-92.8%, I2  = 70.5%) for EUS-RV and 94.1% (95% CI 91.1-97.1%, I2  = 59.2%) for PERC-RV (P = 0.088). The technical success rates of EUS-RV and PERC-RV were comparable in subgroups of benign diseases (89.2% vs. 95.8%, P = 0.068), malignant diseases (90.3% vs. 95.5%, P = 0.193), and normal anatomy (90.7% vs. 95.9%, P = 0.240). However, patients with surgically altered anatomy had poorer technical success after EUS-RV than after PERC-RV (58.7% vs. 93.1%, P = 0.036). The pooled rates of overall adverse events were 9.8% for EUS-RV and 13.4% for PERC-RV (P = 0.686).

CONCLUSIONS

Both EUS-RV and PERC-RV have exhibited high technical success rates. When standard ERCP fails, EUS-RV and PERC-RV are comparably effective rescue techniques if adequate expertise and facilities are feasible. However, in patients with surgically altered anatomy, PERC-RV might be the preferred choice over EUS-RV because of its higher technical success rate.

Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.

METHODS

A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.

RESULTS

One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%).

CONCLUSIONS

Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.

Endoscopic Ultrasound-guided Versus Percutaneous Transhepatic Biliary Drainage After Failed ERCP: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may fail to achieve biliary drainage in 5% to 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) are alternative therapeutic options in such cases. The present meta-analysis aimed to compare the efficacy and safety of EUS-BD and PTBD for biliary decompression after failed ERCP.

METHODS

A comprehensive search of literature from inception to September 2022 was done of 3 databases for studies comparing EUS-BD and PTBD for biliary drainage after failed ERCP. Odds ratios (ORs) with 95% CIs were calculated for all the dichotomous outcomes. Continuous variables were analyzed using mean difference (MD).

RESULTS

A total of 24 studies were included in the final analysis. Technical success was comparable between EUS-BD and PTBD (OR=1.12, 0.67-1.88). EUS-BD was associated with a higher clinical success rate (OR=2.55, 1.63-4.56) and lower odds of adverse events (OR=0.41, 0.29-0.59) compared with PTBD. The incidence of major adverse events (OR=0.66, 0.31-1.42) and procedure-related mortality (OR=0.43, 0.17-1.11) were similar between the groups. EUS-BD was associated with lower odds of reintervention with an OR of 0.20 (0.10-0.38). The duration of hospitalization (MD: -4.89, -7.73 to -2.05) and total treatment cost (MD: -1355.46, -2029.75 to -681.17) were significantly lower with EUS-BD.

CONCLUSIONS

EUS-BD may be preferred over PTBD in patients with biliary obstruction after failed ERCP where appropriate expertise is available. Further trials are required to validate the findings of the study.

Percutaneous insertion of a novel dedicated metal stent to treat malignant hilar biliary obstruction

BACKGROUND

Percutaneous bilateral biliary stenting is an established method for the management of unresectable malignant hilar biliary obstruction.

AIM

To evaluate the efficacy and safety of a novel uncovered biliary stent, specifically designed for hilar reconstruction.

METHODS

This, single-center, retrospective study included 18 patients (mean age 71 ± 11 years; 61.1% male) undergoing percutaneous transhepatic Moving cell stent (MCS) placement for hilar reconstruction using the stent-in-stent technique for malignant biliary strictures, between November 2020 and July 2021. The Patients were diagnosed with cholangiocarcinoma (12/18; 66.6%), gallbladder cancer (5/18; 27.7%), and colorectal liver metastasis (1/18; 5.5%). Primary endpoints were technical (appropriate stent placement) and clinical (relief from jaundice) success. Secondary endpoints included stent patency, overall survival, complication rates and stent-related complications.

RESULTS

The technical and clinical success rates were 100% (18/18 cases). According to Kaplan-Meier analysis, the estimated overall patient survival was 80.5% and 60.4% at 6 and 12 mo respectively, while stent patency was 90.9% and 68.2% at 6 mo and 12 mo respectively. The mean stent patency was 172.53 ± 56.20 d and median stent patency was 165 d (range 83-315). Laboratory tests for cholestasis significantly improved after procedure: mean total bilirubin decreased from 15.2 ± 6.0 mg/dL to 1.3 ± 0.4 mg/dL (P < 0.001); mean γGT decreased from 1389 ± 832 U/L to 114.6 ± 53.5 U/L (P < 0.001). One periprocedural complication was reported. Stent-related complications were observed in 5 patients (27.7%), including 1 occlusion (5.5%) and 1 stent migration (5.5 %).

CONCLUSION

Percutaneous hilar bifurcation biliary stenting with the MCS resulted in excellent clinical and technical success rates, with acceptable complication rates. Further studies are needed to confirm these initial positive results.

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

Comparing Outcomes Following Endoscopic Ultrasound-Guided Biliary Drainage Versus Percutaneous Transhepatic Biliary Drainage for Malignant Biliary Obstruction: A Systematic Review and Meta-Analysis

Background: The aim of this study was to explore the efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTCD) in patients with malignant biliary obstruction and failed endoscopic retrograde cholangiopancreatography. Methods: We searched PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov to identify studies reporting outcomes comparing EUS-BD and PTCD. Results: We identified 9 studies involving 469 patients. Technical success was similar for EUS-BD and PTCD (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.17-3.30; P = .71). EUS-BD was associated with higher clinical success versus PTCD (OR, 2.11; 95% CI, 1.15-3.87; P = .02) in all studies. However, there was no significant difference between groups in studies using self-expandable metal stents (OR, 0.36; 95% CI, 0.06-2.00; P = .24). The reported adverse event rate was significantly lower for EUS-BD compared with PTCD (OR, 0.33; 95% CI, 0.22-0.52; P < .00001). Conclusion: The available literature suggests that EUS-BD is associated with fewer adverse events, greater clinical success, and comparable technical success compared with PTCD. According to the shortcomings of our study, more large, high-quality, randomized controlled trials are needed to compare these techniques and confirm our findings.

EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent placement should replace PTBD after ERCP failure in patients with distal tumoral biliary obstruction: a large real-life study

AIMS

In cases of malignant distal biliary obstruction, ERCP is the preferred technique for bile duct drainage. In case of failure, the alternative techniques are percutaneous transhepatic biliary drainage (PTBD) and more recently endoscopic ultrasound-guided biliary drainage. A new type of stent called the electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) has been developed to enable the performance of biliary-enteric anastomosis under EUS-guidance in a single step, without prior bile duct puncture or the need for a guidewire. The aim of our study was to compare the real-life efficacies of PTBD and EUS-BD with the EC-LAMS for cases of ERCP failure in patients with malignant biliary obstruction.

METHODS

We performed a monocentric retrospective study comparing PTBD and EUS-BD with the use of electrocautery-enhanced lumen-apposing metal stent in the context of a malignant distal biliary obstruction after ERCP failure.

RESULTS

95 patients were included (50 in EUS-BD group and 45 in PTBD group). The main etiology of malignant obstruction was adenocarcinoma of the head of pancreas (85%). There was a significant difference in favor of endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced lumen-apposing metal stent for the following criteria: clinical success: 89.3% vs. 45.5%; p < 0.0001; procedure-related adverse event rate: 2.12% vs. 22.7%; p = 0.003; duration of post-drainage hospitalization: 3.5 vs. 8.2 days; p < 0.0001, overall survival (median survival): 118.2 vs. 42 days; p = 0.012, overall cost of the strategy per patient: 5098 vs. 9363 euros; p < 0.001.

CONCLUSION

Our results are in favor of EUS-BD using electrocautery-enhanced lumen-apposing metal stent in case of ERCP failure for a distal tumor biliary obstruction. Operators performing ERCP for distal tumor biliary obstruction must learn this backup procedure because of its superiority over percutaneous transhepatic biliary drainage in terms of clinical success, safety, cost, and overall survival.

Role of Interventional Radiology in the Management of Acute Cholangitis

Acute cholangitis presents with a wide severity spectrum and can rapidly deteriorate from local infection to multiorgan failure and fatal sepsis. The pathophysiology, diagnosis, and general management principles will be discussed in this review article. The focus of this article will be on the role of biliary drainage performed by interventional radiology to manage acute cholangitis. There are specific scenarios where percutaneous drainage should be preferred over endoscopic drainage. Percutaneous transhepatic and transjejunal biliary drainage are both options available to interventional radiology. Additionally, interventional radiology is now able to manage these patients beyond providing acute biliary drainage including cholangioplasty, stenting, and percutaneous cholangioscopy/biopsy.

Endoscopic ultrasound-guided biliary drainage in benign biliary pathology with normal foregut anatomy: a multicenter study

BACKGROUND AND AIMS

Biliary drainage using endoscopic ultrasound (EUS-BD) has been developed as a novel technique to obtain biliary access and drainage when ERCP fails. Numerous studies have demonstrated its safety and efficacy specifically pertaining to those with malignant distal biliary obstruction or altered foregut anatomy. The aim of this study is to evaluate the safety and efficacy of EUS-BD in benign indications in patients with normal foregut anatomy.

METHODS

We performed a retrospective comparative study from 5 academic medical centers (2008-2018) involving patients with benign biliary obstruction and native foregut anatomy who had an initial failed ERCP with subsequent attempt at biliary decompression via EUS-BD or by repeating ERCP.

RESULTS

36 patients (mean age 61.6 ± 2.2, 38.9% female) who underwent attempted EUS-BD following initial failed ERCP were compared to 50 patients (mean age 62.7 ± 2.3, 73.5% female) who underwent repeat ERCP following an initial failed cannulation. EUS-BD was technically successful in 28 (77.8%) patients with rendezvous being the most common approach (86.1%). A higher level of pre-procedural bilirubin was found to be associated with technical success of EUS-BD (3.65 ± 0.63 versus 1.1 ± 0.4, p value 0.04). Success of repeat ERCP following failed cannulation was 86%. Adverse events were significantly more frequent in the EUS-BD cohort when compared to the repeat ERCP (10 (27.8%) versus 4 (8.0%), p = 0.02, OR 4.32.

CONCLUSIONS

EUS-BD remains a viable therapeutic option in the setting of benign biliary disease, with success rates of 77.8%. Adverse events were significantly more common with EUS-BD vs. repeat ERCP, emphasizing the need to perform in expert centers with appropriate multidisciplinary support and to strongly consider the urgency of biliary decompression before considering same session EUS-BD after failed initial biliary access.

ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: a multicenter observational open-label study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may not provide complete biliary drainage in patients with Bismuth III/IV malignant hilar biliary obstruction (MHBO). Complete biliary drainage is accomplished by adding percutaneous transhepatic biliary drainage (PTBD). We prospectively compared recurrent biliary obstruction (RBO) rates between combined ERCP and endoscopic ultrasound-guided biliary drainage (EUS-BD) vs. bilateral PTBD.

METHODS

Patients with MHBO undergoing endoscopic procedures (group A) were compared with those undergoing bilateral PTBD (group B). The primary outcome was the 3-month RBO rate.

RESULTS

36 patients were recruited into groups A (n = 19) and B (n = 17). Rates of technical and clinical success, and complications of group A vs. B were 84.2 % (16/19) vs. 100 % (17/17; P = 0.23), 78.9 % (15/19) vs. 76.5 % (13/17; P > 0.99), and 26.3 % (5/19) vs. 35.3 % (6/17; P = 0.56), respectively. Within 3 and 6 months, RBO rates of group A vs. group B were 26.7 % (4/15) vs. 88.2 % (15/17; P  = 0.001) and 22.2 % (2/9) vs. 100 % (9/9; P = 0.002), respectively. At 3 months, median number of biliary reinterventions in group A was significantly lower than in group B (0 [interquartile range] 0-1 vs. 1 [1-2.5]), respectively (P < 0.001). Median time to development of RBO was longer in group A than in group B (92 [56-217] vs. 40 [13.5-57.8] days, respectively; P  =  0.06).

CONCLUSIONS

Combined ERCP and EUS procedures provided significantly lower RBO rates at 3 and 6 months vs. bilateral PTBD, with similar complication rates and no significant mortality difference.

A Proposed Algorithm for Endoscopic Ultrasound-Guided Rendezvous Technique in Failed Biliary Cannulation

Background: The selection of an approach route in endoscopic ultrasound-guided rendezvous (EUS-RV) for failed biliary cannulation is complicated. We proposed an algorithm for EUS-RV. Methods: We retrospectively evaluated consecutive EUS-RV cases between April 2017 and July 2020. Puncturing the distal extrahepatic bile duct (EHBD) from the duodenal second part (D2) (DEHBD/D2 route) was attempted first. If necessary, puncturing the proximal EHBD from the duodenal bulb (D1) (PEHBD/D1 route), puncturing the left intrahepatic bile duct (IHBD) from the stomach (LIHBD/S route), or puncturing the right IHBD from the D1 (RIHBD/D1 route) were attempted in this order. Results: A total of 16 patients were included. The DEHBD/D2 route was used in 10 (62.5%) patients. The PEHBD/D1 route was attempted in five (31.3%) patients, and the biliary puncture failed in one patient in whom the RIHBD/D1 route was used because of tumor invasion to the left hepatic lobe. The LIHBD/S route was applied in one (6.3%) patient. Successful biliary cannulation was achieved in all patients eventually. The time from the puncture to the guidewire placement in the DEHBD/D2 route (3.5 min) was shorter than that in other methods (14.0 min) (p = 0.014). Adverse events occurred in one (6.3%) patient with moderate pancreatitis. Conclusions: The proposed algorithm might be useful for the selection of an appropriate approach route in EUS-RV.

Current Endoscopic Management of Malignant Biliary Stricture

Biliary and pancreatic cancers occur silently in the initial stage and become unresectable within a short time. When these diseases become symptomatic, biliary obstruction, either with or without infection, occurs frequently due to the anatomy associated with these cancers. The endoscopic management of these patients has changed, both with time and with improvements in medical devices. In this review, we present updated and integrated concepts for the endoscopic management of malignant biliary stricture. Endoscopic biliary drainage had been indicated in malignant biliary obstruction, but the concept of endoscopic management has changed with time. Although routine endoscopic stenting should not be performed in resectable malignant distal biliary obstruction (MDBO) patients, endoscopic biliary drainage is the treatment of choice for palliation in unresectable MDBO patients. Self-expanding metal stents (SEMS) have better stent patency and lower costs compared with plastic stents (PS). For malignant hilum obstruction, PS and uncovered SEMS yield similar short-term outcomes, while a covered stent is not usually used due to a potential unintentional obstruction of contralateral ducts.

EUS-guided biliary drainage for difficult cannulation

EUS-guided biliary drainage (EUS-BD) has been recognized as a new alternative to failed ERCP. The alternatives for failed/impossible ERCP in cases of difficult and selective bile duct cannulation include percutaneous transhepatic BD (PTBD) with precut papillotomy. EUS-BD is reportedly more convenient than PTBD and more successful than precut papillotomy, suggesting that EUS-BD is the next step following failed/impossible ERCP.

Palliative Endoscopic Ultrasound Biliary Drainage for Advanced Malignant Biliary Obstruction: Should It Replace the Percutaneous Approach?

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are the standard of care in malignant biliary obstruction cases. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used after unsuccessful ERCP. However, the patient's clinical impact of EUS-BD over PTBD is still not obvious. Therefore, this case series study aims to evaluate the clinical outcomes of patients with advanced malignant biliary obstruction who underwent EUS-BD after failed ERCP. A retrospective database study was performed between January 2016 and June 2018 in patients with advanced malignant biliary obstruction. Patients were consecutively enrolled without randomization. Treatment options consisted of ERCP and PTBD or EUS-BD if ERCP failed. Based on 144 biliary obstruction cases, 38 patients were enrolled; 24 (63.2%) were men. The patients' mean age was 66.8 ± 12.36 years. The most common cause of malignant biliary obstruction was pancreatic cancer (44.7%). Biliary drainage was achieved by ERCP (39.5%), PTBD (39.5%), and EUS-BD (21.1%). The technical success rate was 86.7% by PTBD and 87.5% by EUS-BD (p = 1.000), while the clinical success rate was 93.3% by PTBD and 62.5% by EUS-BD (p = 0.500). The median survival in patients who underwent PTBD versus those wo underwent EUS-BD was 11 versus 3 months (log-rank p = 0.455). In conclusion, there is no significant advantage of EUS-BD when compared to PTBD in terms of clinical success and survival benefit in advanced malignant biliary obstruction.

Endoscopic palliation of biliary obstruction

Advanced pancreaticobiliary malignancy tends to be uncurable at presentation and causes significant morbidity for patients. Palliation for malignant biliary obstruction should be minimally invasive, cost-effective, and aim to improve quality of life of patients. Strategies of endoscopic palliation of malignant biliary obstruction can differ based on sites and degree of biliary obstruction with complex decisions of optimal stent type and placement that involve conscientious planning by a multidisciplinary team.

Endoscopic ultrasound-guided drainage of the biliary system: Techniques, indications and future perspectives

Over the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved into a widely accepted alternative to the percutaneous approach in cases of biliary obstruction with failed endoscopic retrograde cholangiopancreaticography (ERCP). The available evidence suggests that, in experienced hands, EUS-BD might even replace ERCP as the first-line procedure in specific situations such as malignant distal bile duct obstruction. The aim of this review is to summarize the available data on EUS-BD and propose an evidence-based algorithm clarifies the role of the different EUS-BD techniques in the management of benign and malignant biliary obstructive disease.

Interventional radiology-operated endoscopy-assisted retrograde transnasal placement of a retrievable transhepatic covered biliary stent

Biliary stent placement is an adjunct for complex biliary intervention. Patients with benign biliary strictures or aversion to external drainage may benefit from placement of retrievable biliary stents. This report describes a patient with a working diagnosis of benign biliary stricture who underwent interventional radiology-operated endoscopy-guided transnasal placement of a fully covered retrievable biliary stent.

Endoscopic Ultrasound-Guided Biliary Drainage Using Self-Expandable Metal Stent for Malignant Biliary Obstruction

Purpose. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been increasingly reported worldwide. However, studies concerning EUS-BD from Mainland China are sporadic. This study aims to investigate the feasibility, efficacy, and safety of EUS-BD using SEMS in a single center from Mainland China. Methods. Between November 2011 and August 2015, 24 patients underwent EUS-BD using a standardized algorithm. Results. Three patients underwent rendezvous technique (RV), 4 underwent hepaticogastrostomy (HGS), and 17 underwent choledochoduodenostomy (CDS). The technical and clinical success rates were 95.8% (23/24) and 100% (23/23), respectively. Mean procedure time for the CDS group (35.9 ± 5.0 min) or HGS group (39.3 ± 5.0 min) was significantly shorter than that for the RV group (64.7 ± 9.1 min) (P < 0.05). Complications (13%) included (1) cholangitis and (2) postprocedure hemorrhage. During the follow-up periods (mean 6.4 months), 22 (91.7%) patients died of tumor progression with mean stent patency of 5.8 ± 2.2 months. Stent occlusion occurred in 2 (8.7%) patients. Conclusion. EUS-BD using SEMS is a feasible, effective, and safe alternative for biliary decompression after failed ERCP. EUS-RV may not be the first-line choice for EUS-BD in a medium volume center. Further evaluation and experience of this method are needed.