Single-operator EUS-guided cholangiopancreatography for difficult pancreaticobiliary access (with video)

Background: When conventional ERCP methods fail because of periampullary or ductal obstruction, EUS-guided cholangiopancreatography (EUS-CP) may aid in pancreaticobiliary access. Objective: To report our experience when using single-operator EUS-CP. Setting: An academic tertiary-referral center. Methods: Consecutive patients undergoing EUS-CP were prospectively identified. These patients had undergone failed attempt(s) at therapeutic ERCP. A data sheet was used to record indications, reasons for failed ERCP, EUS-CP visualization of the duct of interest, transpapillary or transenteric intervention, clinical follow-up, and complications. Main Outcome Measurements: Technical success was decompression of the duct of interest. Clinical success was resolution of jaundice or a ≥50% reduction in pain or narcotics, as applicable. Results: Between February 2003 and June 2007, EUS-CP was attempted in 20 patients (11 men, 9 women; mean [SD] age 58 ± 14.9 years). Indications included jaundice (n = 8), biliary stones (n = 3), chronic pancreatitis (n = 6), acute pancreatitis (n = 2), and papillary stenosis (n = 1). Reasons for failed ERCP included periampullary mass (n = 8), intradiverticular papillae (n = 4), and pancreatic duct (PD) stricture (n = 7) or stone (n = 1). Technical success was achieved in 18 of 20 patients (90%). Biliary decompression was obtained in 11 of 12 patients (92%) (7 transpapillary and 4 transenteric-transcholedochal). Pancreatic decompression was obtained in 7 of 8 patients (88%) (3 transpapillary, 4 transgastric). On follow-up, clinical improvement was noted in 15 of 20 patients (70%). For treatment of pain associated with chronic pancreatitis, pain scores decreased by a mean of 1.75 (P = .18). Complications (in 2 of 20 [10%]) included perforation (n = 1) and respiratory failure (n = 1). Limitations: A single-center nonrandomized observational study with a small patient population. Conclusions: At our academic referral center, single-operator EUS-CP provided decompression of obstructed ducts and may be performed after a failed attempt at conventional ERCP during the same endoscopic session.