Endoscopic ultrasound-directed transenteric ERCP in patients with benign and malignant diseases and inaccessible biliary system

Background and study aims: Patients requiring biliary interventions with endoscopically inaccessible papilla or biliodigestive anastomosis represent a challenge in clinical practice. Historically, percutaneous transhepatic biliary drainage (PTBD) has often been the only viable treatment after failed endoscopic attempts. Recently, endoscopic ultrasound (EUS)-guided techniques have emerged as promising alternatives. This study evaluated the feasibility and safety of EUS-guided transenteric ERCP (EDEE) at a tertiary referral center. Patients and methods: This retrospective, single-center study included patients who underwent EDEE between February 2020 and November 2025. Primary endpoints were safety and overall technical success, defined as successful creation of an EUS-guided anastomosis (EA) using a lumen-apposing metal stent (LAMS) followed by endoscopic retrograce cholangiopancreatography (ERCP) via LAMS. Secondary endpoints included clinical success, need for reinterventions, and procedure characteristics. Results: A total of 24 patients (70.3 ± 12.6 years; 6 female) were analyzed. Sixteen patients had surgically altered anatomy (5 Whipple, 11 Roux-en-Y), and eight presented with malignant gastric outlet obstruction. EA and ERCP via LAMS were conducted in two stages with a median interval of 29.5 days. In 15 patients, the afferent loop was accessed after filling via a previously placed PTBD, which was removed after EDEE. Technical success was 100% (24/24) for EA and 87.5% (21/24) for ERCP via LAMS; overall technical and clinical success were 87.5% (21/24). Procedure-related complications occurred in two patients (8.3%), including one aspiration pneumonia and one LAMS misplacement. Conclusions: This study suggests that EDEE is a feasible and safe method for biliary drainage in patients with inaccessible biliary anatomy, demonstrating high technical and clinical success in both malignant and benign conditions being performed at a highly specialized tertiary center.