EUS-guided hepaticogastrostomy in the management of malignant biliary obstruction: Experience and learning curve in a tertiary referral center.

ABSTRACT

BACKGROUND: EUS-guided hepaticogastrostomy (EUS-HGS) is a recognized second-line strategy for biliary drainage when endoscopic retrograde cholangiopancreatography fails or is impossible. Substantial technical and procedural progress in performing EUS-HGS has been achieved. The present study wanted to analyze whether growing experience in current practice has changed patient outcomes over time. METHODS: We retrospectively analyzed data from patients with malignant biliary obstruction treated by EUS-HGS between 2002 and 2018 at a tertiary referral center. RESULTS: A total of 205 patients were included (104 male; mean age 68 years). Clinical success was achieved in 93% of patients with available 30-days follow-up (153), and the rate of procedure-related morbidity and mortality after one month was 18% and 5%, respectively. The cumulative sum (CUSUM) learning curve suggests a slight improvement in the rate of early complications during the second learning phase (23% vs 32%; P = 0.14; including death for any cause and intensive care). However, a significant threshold of early complications could not be determined. Recurrent biliary stent occlusion is the main cause for endoscopic reintervention (47/130; 37%). CONCLUSION: The rate of procedure-related complications after EUS-HGS has improved over time. However, the overall morbidity rate remains high, emphasizing the importance of dedicated expertise, appropriate patient selection and multidisciplinary discussion.