Enhancing Pavement Durability: Comparative Rheological Evaluation of Conventional and Rejuvenated Reclaimed Binders under Aging Conditions.

A drawback of recycled mixtures containing reclaimed asphalt is their increased stiffness, further worsened by the accelerated aging of binders in extreme weather conditions. Previous studies have shown that while rejuvenating agents can mitigate some of these issues by improving flexibility and reducing brittleness, they often present challenges, such as performance variability and the potential for rutting. This study aims to develop an optimal blend of reclaimed bitumen, a rejuvenating agent, and pure bitumen to achieve rheological properties similar to a control 35/50 pen-grade bitumen for road paving. Hence, the rejuvenated binders comprised 30:70 blends of reclaimed asphalt bitumen and 50/70 pen-grade bitumen, adding 0.2% to 0.6% of a rejuvenating agent by mass of the reclaimed asphalt. Sample testing included conventional penetration grade, softening point, and viscosity tests, followed by dynamic shear rheometer tests under unaged, short-term, and long-term aging conditions. The results show that the binder blend with 0.4% rejuvenator closely resembles the rheological properties of 35/50 pen-grade bitumen. This blend exhibits a 20% to 55% stiffness reduction for recycled mixtures with 30% reclaimed asphalt. Notably, the rejuvenated binders exhibited a similar level of aging resistance to the control bitumen, with a marginal difference of less than 5% in aging ratios. Meanwhile, large strain amplitude tests showed the importance of defining maximum rejuvenating incorporation rates in recycled mixtures to avoid rutting problems, where binders with 0.4% rejuvenator doubled the rutting potential (Jnr values). This innovative study highlights the potential for enhancing recycled mixtures' performance by evaluating rejuvenated reclaimed binders' rheology subjected to different aging conditions, thus contributing to sustainability in pavement construction.

In-water resuscitation during a surf rescue: Time lost or breaths gained? A pilot study.

BACKGROUND: A technique called in-water resuscitation (IWR) was devised on a surfboard to ventilate persons who seemingly did not breathe upon a water rescue. Despite IWR still raises uncertainties regarding its applicability, this technique is recommended by the International Liaison Committee for Resuscitation (ILCOR). Thus, this study aimed to evaluate the feasibility of IWR with a rescue board before and during towing and, to compare rescue times and rescue-associated fatigue levels between rescues with rescue breath attempts and without (SR). METHODS: A randomized crossover pilot test was conducted: 1) IWR test with pocket mask and, 2) Conventional SR test. IWR tests were conducted using a Laerdal ResusciAnne manikin (Stavanger, Norway). Three groups of variables were recorded: a) rescue time (in s), b) effective ventilations during rescue, and c) rating of perceived effort (RPE). RESULTS: Focusing on the rescue time, the performance SR was significantly faster than IWR rescue which took 61 s longer to complete the rescue (Z = -2.805; p = 0.005). No significant differences were found between techniques for the RPE (T = -1.890; p = 0.095). In the IWR analysis, lifeguards performed an average of 27 ± 12 rescue breaths. CONCLUSION: The application of IWR on a rescue board is feasible both at the time of rescue and during towing. It shortens the reoxygenation time but delays the arrival time to shore. Both IWR and SR result in similar levels of perceived fatigue.

Aquatic Feasibility of Limbs Application of Tourniquets (AFLAT) during a Lifeguard Water Rescue: A Simulation Pilot Study.

INTRODUCTION: Control of massive hemorrhage (MH) is a life-saving intervention. The use of tourniquets has been studied in prehospital and battlefield settings but not in aquatic environments. OBJECTIVE: The aim of this research is to assess the control of MH in an aquatic environment by analyzing the usability of two tourniquet models with different adjustment mechanisms: windlass rod versus ratchet. METHODOLOGY: A pilot simulation study was conducted using a randomized crossover design to assess the control of MH resulting from an upper extremity arterial perforation in an aquatic setting. A sample of 24 trained lifeguards performed two randomized tests: one using a windlass-based Combat Application Tourniquet 7 Gen (T-CAT) and the other using a ratchet-based OMNA Marine Tourniquet (T-OMNA) specifically designed for aquatic use on a training arm for hemorrhage control. The tests were conducted after swimming an approximate distance of 100 meters and the tourniquets were applied while in the water. The following parameters were recorded: time of rescue (rescue phases and tourniquet application), perceived fatigue, and technical actions related to tourniquet skills. RESULTS: With the T-OMNA, 46% of the lifeguards successfully stopped the MH compared to 21% with the T-CAT (P = .015). The approach swim time was 135 seconds with the T-OMNA and 131 seconds with the T-CAT (P = .42). The total time (swim time plus tourniquet placement) was 174 seconds with the T-OMNA and 177 seconds with the T-CAT (P = .55). The adjustment time (from securing the Velcro to completing the manipulation of the windlass or ratchet) for the T-OMNA was faster than with the T-CAT (six seconds versus 19 seconds; P < .001; effect size [ES] = 0.83). The perceived fatigue was high, with a score of seven out of ten in both tests (P = .46). CONCLUSIONS: Lifeguards in this study demonstrated the ability to use both tourniquets during aquatic rescues under conditions of fatigue. The tourniquet with the ratcheting-fixation system controlled hemorrhage in less time than the windlass rod-based tourniquet, although achieving complete bleeding control had a low success rate.

The Effect of Microwave Radiation on the Self-Healing Performance of Asphalt Mixtures with Steel Slag Aggregates and Steel Fibers.

Self-healing in asphalt mixtures is a property that can be enhanced by external heating, which causes a thermal expansion that increases the flow of bitumen with reduced viscosity through the cracks. Therefore, this study aims to evaluate the effects of microwave heating on the self-healing performance of three asphalt mixtures: (1) conventional, (2) with steel wool fibers (SWF), and (3) with steel slag aggregates (SSA) and SWF. After evaluating the microwave heating capacity of the three asphalt mixtures with a thermographic camera, their self-healing performance was determined with fracture or fatigue tests and microwave heating recovery cycles. The results demonstrated that the mixtures with SSA and SWF promoted higher heating temperatures and presented the best self-healing capacity during the semicircular bending test and heating cycles, with significant strength recovery after a total fracture. In contrast, the mixtures without SSA presented inferior fracture results. Both the conventional mixture and that containing SSA and SWF presented high healing indexes after the four-point bending fatigue test and heating cycles, with a fatigue life recovery of around 150% after applying two healing cycles. Therefore, the conclusion is that SSA greatly influences the self-healing performance of asphalt mixtures after microwave radiation heating.

Surfers as aquatics rescuers in Portugal and Spain: Characteristics of rescues and resuscitation knowledge.

The aim of this study was to analyze the rescues carried out by surfers from Portugal and Spain, their knowledge of rescue and resuscitation and their perception and risk behavior while surfing. An online survey was conducted in 2048 surfers from Portugal and Spain, with questions regarding the demographic characteristics, experience, perception and risk behavior of the surfers; rescues attended by the surfers and surfer's knowledge and experience in rescue and resuscitation. Concerning the number of rescues carried out by surfers, 78.5% of the participants had to carry out at least one rescue in their lifetime. A significant association was found between the years of surfing experience, the surfing level and the number of rescues carried out (p < 0.05). Thirty-five-point eight percent of the surfers never attended a cardiopulmonary resuscitation (CPR) course and 76.2% had no work experience as a lifeguard. Correspondingly, the vast majority of the surfers analyzed did not have the essential knowledge about rescue and resuscitation. This study provides evidence of the important role that surfers play in saving lives on Portuguese and Spanish beaches. The results suggest that the number of rescues conducted by surfers each year in Portugal and Spain is relevant to reducing the number of fatalities that occur along coasts.

[Perception, knowledge and education for drowning prevention in adolescent.] / Percepciones, conocimientos y educación para la prevención del ahogamiento en adolescentes.

OBJECTIVE: Drowning is a major problem of public health in Spain, with a high number of deaths. The main strategy to address it is prevention, going through knowledge and education. The aim of this study was to analyze from a public health perspective a) the knowledge of young participants from 14 to 16 years old about drowning prevention, swimming skills and risks on the beach and b) to evaluate a pilot program with educational video for drowning prevention due to rip currents. METHODS: For this purpose, a three-phase study was carried out: (1) application of a questionnaire to identify bath habits, risk perception in relation to rip currents and swimming level, (2) evaluation of a video for the identification of rip current risk and (3) evaluation of the assimilation of the visualized content one month after the intervention. 120 adolescents participated in this study during march, april and may, 2019. A descriptive analysis and comparisons with Chi-Square were performed in SPSS. RESULTS: 120 adolescents participated in this study during March, April and May, 2019. 96.7% knew how to swim, but 44.1% had a basic level. More than half of the participants did not know rip currents or did not identify them in swimming areas. The video achieves the assimilation of concepts related to rip currents and drowning prevention. CONCLUSIONS: These findings suggest that adolescents have a lack of knowledge about rip currents and are not able to identify safe swimming areas. The use of health communication strategies based on the interests and profiles of young people have shown an improvement in the perception of risks at beaches on the sample studied.

OBJETIVO: El ahogamiento es un problema de salud pública en España, con un gran número de muertes. La principal estrategia para abordarlo es la prevención, que debe pasar por el conocimiento y la educación de las personas. El objetivo de este estudio fue analizar desde la perspectiva de salud pública: a) los conocimientos de adolescentes entre 14 y 16 años sobre prevención del ahogamiento, habilidades de natación y riesgos en la playa y b) evaluar un programa piloto de formación mediante un video educativo para prevenir ahogamiento por corrientes de resaca. METODOS: Se realizó un estudio en tres fases: (1) aplicación de un cuestionario para identificar los hábitos de baño, la percepción del riesgo con relación a las corrientes de resaca y el nivel de natación, (2) evaluación de un programa formativo mediante un vídeo y (3) evaluación de la asimilación del contenido visualizado tras un mes. 120 adolescentes participaron en este estudio durante los meses de marzo, abril y mayo del 2019. Se realizó un análisis estadístico descriptivo y de comparaciones mediante la prueba Chi-Cuadrado con el programa SPSS. RESULTADOS: El 96,7% sabían nadar, pero 44,1% tenían un nivel básico. Más de la mitad no conocían las corrientes de resaca o no las identificaron en zonas de baño. La intervención educativa mediante un vídeo logró mejorar el conocimiento. CONCLUSIONES: Los adolescentes tienen una falta de conocimiento sobre las corrientes de resaca y no son capaces de identificar zonas de baño seguras. El uso de estrategias de comunicación para la salud, basadas en los intereses y perfiles de personas jóvenes han mostrado una mejora en la percepción de los riesgos en las playas en la muestra estudiada.

EUS-guided gastroenterostomy: Initial experience in a brazilian tertiary center.

INTRODUCTION: EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO). Our aim was to evaluate the outcomes of this technique in our initial experience. METHODS: Patients with GOO from our institute were included. Technical success was defined as the successful creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a soft diet after the procedure. We assessed adverse events and diet tolerance 1 month after the procedure. RESULTS: Three patients were included. Technical and clinical success was achieved in all cases. There were no adverse events and good diet tolerance was observed 1 month after the procedure in the included patients. CONCLUSION: EUS-GE is a promising treatment for patients with GOO.

EUS-guided gastroenterostomy: Initial experience in a brazilian tertiary center

SUMMARY INTRODUCTION: EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO). Our aim was to evaluate the outcomes of this technique in our initial experience. METHODS: Patients with GOO from our institute were included. Technical success was defined as the successful creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a soft diet after the procedure. We assessed adverse events and diet tolerance 1 month after the procedure. RESULTS: Three patients were included. Technical and clinical success was achieved in all cases. There were no adverse events and good diet tolerance was observed 1 month after the procedure in the included patients. CONCLUSION: EUS-GE is a promising treatment for patients with GOO.

RESUMO INTRODUÇÃO: A gastroenterostomia ecoguiada é um novo procedimento para paliação da obstrução maligna gastroduodenal. Nosso objetivo foi avaliar os resultados dessa técnica em nossa experiência inicial. MÉTODOS: Foram incluídos pacientes com obstrução maligna gastroduodenal de nossa instituição. O sucesso técnico foi definido como a realização adequada de uma gastroenterostomia. O sucesso clínico foi definido como boa aceitação de dieta pastosa durante a internação. Os eventos adversos e a aceitação alimentar foram avaliados um mês após o procedimento. RESULTADOS: Três pacientes foram incluídos. Os sucessos técnico e clínico foram alcançados em todos os casos. Não houve eventos adversos e a aceitação alimentar permaneceu adequada um mês após o procedimento nos pacientes incluídos. CONCLUSÃO: O EUS-GE é um tratamento promissor para pacientes com obstrução maligna gastroduodenal.

Does a history of head and neck cancer affect outcome of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma?

Background and study aims Esophageal squamous cell carcinoma (ESCC) is the most common secondary tumor in patients with head and neck squamous cell cancer (HNSCC). Currently, endoscopic submucosal dissection (ESD) is the preferred approach to manage superficial ESCC, however, it remains to be elucidated whether patients with HNSCC and early ESCC managed by ESD have different outcomes. Patients and methods We retrospectively analyzed esophageal ESD for early ESCC from September 2009 to September 2017 and the following variables: demographics, tumor and specimen size, Paris classification, location, en bloc and R0 resection rates, overall survival (OS) and adverse events (AEs). To reduce selection bias, propensity score matching was applied to compare the results. Results Eighty-nine ESDs were performed in 81 consecutive patients (47 with HNSCC and 34 without HNSCC). Patients with HNSCC who developed superficial ESCC were found to be younger and to refer a more frequent history of alcohol ingestion and smoking. There was no difference in lesion size, number of lesions, procedure time, en bloc resection rate, R0 resection rate, local recurrence and adverse event rate between the two groups. The histological depth of invasion for patients with HNSCC was significantly shallower before ( P  = 0.016) and after ( P  = 0.047) matching. The overall survival rate was similar in both groups. Conclusions Patients with HNSCC have earlier detection of ESCC, probably due to endoscopic screening. Previous history of chemoradiation and surgery for HNSCC does not affect procedure time, AEs and OS.

Larval development and proteolytic activity of Anticarsia gemmatalis Hübner (Lepidoptera: Noctuidae) exposed to different soybean protease inhibitors.

Anticarsia gemmatalis represents a relevant factor for lowering soybean and other legume crop productivities. Protease inhibitors affect protein degradation and reduce the availability of amino acids, impairing the development and survival of insect pests. To evaluate the possible use of proteinaceous protease inhibitors in the management of this pest, the activities of midgut proteases and the growth and development of A. gemmatalis larvae exposed to soybean Bowman-Birk trypsin-chymotrypsin inhibitor (SBBI) and soybean Kunitz trypsin inhibitor (SKTI) were determined. The survival curves obtained using Kaplan-Meier estimators indicated that SKTI and SBBI stimulated larval survival. However, the development of A. gemmatalis was delayed, and prepupal weight decreased in the presence of both inhibitors. The results showed that SKTI and SBBI inhibited the trypsin-like and total proteolytic activities of larvae on the 12th day after eclosion. On the 15th day after eclosion, larvae exposed to SKTI increased the activities of trypsin and total proteases. Although SKTI and SBBI did not affect the survival of the insect, they had effects on midgut proteases in a stage wherein A. gemmatalis fed voraciously, increased the larval cycle, and decreased prepupal weight. These findings provide baseline information about the potential of proteinaceous protease inhibitors to manage the velvetbean caterpillar, avoiding chemical pesticides.

Validation of classic and expanded criteria for endoscopic submucosal dissection of early gastric cancer: 7 years of experience in a Western tertiary cancer center.

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher's exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with "only-by-size" expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries.

Validation of classic and expanded criteria for endoscopic submucosal dissection of early gastric cancer: 7 years of experience in a Western tertiary cancer center

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher's exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with "only-by-size" expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries.

II Brazilian consensus statement on endoscopic ultrasonography.

BACKGROUND AND OBJECTIVES: At the time of its introduction in the early 80s, endoscopic ultrasonography (EUS) was indicated for diagnostic purposes. Recently, EUS has been employed to assist or to be the main platform of complex therapeutic interventions. METHODS: From a series of relevant new topics in the literature and based on the need to complement the I Brazilian consensus on EUS, twenty experienced endosonographers identified and reviewed the pertinent literature in databases. The quality of evidence, strength of recommendations, and level of consensus were graded and voted on. RESULTS: Consensus was reached for eight relevant topics: treatment of gastric varices, staging of nonsmall cell lung cancer, biliary drainage, tissue sampling of subepithelial lesions (SELs), treatment of pancreatic fluid collections, tissue sampling of pancreatic solid lesions, celiac neurolysis, and evaluation of the incidental pancreatic cysts. CONCLUSIONS: There is a high level of evidence for staging of nonsmall cell lung cancer; biopsy of SELs as the safest method; unilateral and bilateral injection techniques are equivalent for EUS-guided celiac neurolysis, and in patients with visible ganglia, celiac ganglia neurolysis appears to lead to better results. There is a moderate level of evidence for: yield of tissue sampling of pancreatic solid lesions is not influenced by the needle shape, gauge, or employed aspiration technique; EUS-guided and percutaneous biliary drainage present similar clinical success and adverse event rates; plastic and metallic stents are equivalent in the EUS-guided treatment of pancreatic pseudocyst. There is a low level of evidence in the routine use of EUS-guided treatment of gastric varices.

Effectiveness of intragastric balloon for obesity: A systematic review and meta-analysis based on randomized control trials.

BACKGROUND: Obesity has become a worldwide epidemic, and many methods are currently used to reduce obesity. This systematic review shows the effectiveness of the intragastric balloon (IGB) method compared to the sham/diet (s/d) method. OBJECTIVE: To demonstrate the effectiveness of the IGB method compared to the s/d method. SETTING: Hospital das Clinicas da Universidade de São Paulo, Brazil, Public Hospital. METHODS: After searching MEDLINE, Embase, Cochrane, Lilacs, Scopus, and CINAHL, only enrolled randomized control trials comparing IGB/diet with s/d were analyzed. For qualitative analysis, 12 studies were selected, and 9 of these were acceptable for quantitative analysis. RESULTS: The IGB/diet is more effective than s/d when comparing body mass index (BMI) loss with a mean difference of 1.1 kg/m(2) by the Student's t test and 1.41 kg/m(2) by the meta-analysis, with significant differences in both. It is also more effective in weight loss (WL), with a mean difference of 2 kg by the Student's t test and 3.55 kg by the meta-analysis. In the qualitative analysis of % excess WL (%EWL), the mean %EWL is 14.0% in favor of the IGB group compared to the s/d group by the Student's t test; however, no significant difference was found between these groups by quantitative analysis. CONCLUSION: Based on randomized control trial data alone, IGB>400 mL is more effective than sham/diet in achieving BMI loss, WL, and %EWL.

Overtube-assisted enteroscopy and capsule endoscopy for the diagnosis of small-bowel polyps and tumors: a systematic review and meta-analysis.

BACKGROUND AND STUDY AIMS: Several studies have evaluated the utility of double-balloon enteroscopy (DBE) and capsule endoscopy (CE) for patients with small-bowel disease showing inconsistent results. The aim of this study was to determine the sensitivity and specificity of overtube-assisted enteroscopy (OAE) as well as the diagnostic concordance between OAE and CE for small-bowel polyps and tumors. PATIENTS AND METHODS: We conducted a systematic review and meta-analysis of studies in which the results of OAE were compared with the results of CE for the evaluation of small-bowel polyps and tumors. When data for surgically resected lesions were available, the histopathological results of OAE and surgical specimens were compared. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the diagnosis of small-bowel polyps and tumors were analyzed. Secondarily, the rates of diagnostic concordance and discordance between OAE and CE were calculated. RESULTS: There were 15 full-length studies with a total of 821 patients that met the inclusion criteria. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were as follows: 0.89 (95 % confidence interval [CI] 0.84 - 0.93), with heterogeneity χ(2) = 41.23 (P = 0.0002) and inconsistency (I (2)) = 66.0 %; 0.97 (95 %CI 0.95 - 0.98), with heterogeneity χ(2) = 45.27 (P = 0.07) and inconsistency (I (2)) = 69.1 %; 16.61 (95 %CI 3.74 - 73.82), with heterogeneity Cochrane's Q = 225.19 (P < 0.01) and inconsistency (I (2)) = 93.8 %; and 0.14 (95 %CI 0.05 - 0.35), with heterogeneity Cochrane's Q = 81.01 (P < .01) and inconsistency (I (2)) = 82.7 %, respectively. A summary receiver operating characteristic curve (SROC) curve was constructed, and the area under the curve (AUC) was 0.97. CONCLUSION: OAE is an accurate test for the detection of small-bowel polyps and tumors. OAE and CE have a high diagnostic concordance rate for small-bowel polyps and tumors. This study was registered in the PROSPERO international database (www.crd.york.ac.uk/prospero/) with the study number CRD42015016000.

Reality named endoscopic ultrasound biliary drainage.

Endoscopic ultrasound (EUS) is used for diagnosis and evaluation of many diseases of the gastrointestinal (GI) tract. In the past, it was used to guide a cholangiography, but nowadays it emerges as a powerful therapeutic tool in biliary drainage. The aims of this review are: outline the rationale for endoscopic ultrasound-guided biliary drainage (EGBD); detail the procedural technique; evaluate the clinical outcomes and limitations of the method; and provide recommendations for the practicing clinician. In cases of failed endoscopic retrograde cholangiopancreatography (ERCP), patients are usually referred for either percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Both these procedures have high rates of undesirable complications. EGBD is an attractive alternative to PTBD or surgery when ERCP fails. EGBD can be performed at two locations: transhepatic or extrahepatic, and the stent can be inserted in an antegrade or retrograde fashion. The drainage route can be transluminal, duodenal or transpapillary, which, again, can be antegrade or retrograde [rendezvous (EUS-RV)]. Complications of all techniques combined include pneumoperitoneum, bleeding, bile leak/peritonitis and cholangitis. We recommend EGBD when bile duct access is not possible because of failed cannulation, altered upper GI tract anatomy, gastric outlet obstruction, a distorted ampulla or a periampullary diverticulum, as a minimally invasive alternative to surgery or radiology.