Biliary drainage in patients with CBGO (benign or malignant). Anterograde transpyloric access to the papilla for ERCP is difficult in the most common type I/II stenosis. Extrahepatic EUS-guided biliary drainage (EUS-BD) achieves suboptimal outocomes in the setting of CBGO, whereas intrahepatic EUS-BD is limited by lack of intrahepatic dilation and by ascites. 

To solve this problem, we propose TRAE (Through-the-LAMS Retrograde Access ERCP). This approach adapts the concept of through-the-LAMS ERCP, currently widely used in patients with post-surgical anatomy, to patients with native anatomy and CBGO. To circumvent antegrade blockage preventing access to the papilla, EUS-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) is first performed. Once EUS-GE is established, a duodenoscope or a therapeutic forward viewing upper endoscope is passed through-the-LAMS to access the papilla. We evaluated the safety and efficacy of TRAE for biliary drainage in non-surgical patients with native anatomy and CBGO. 

A descriptive multicenter study was undertaken. Nineteen patients (71% male; age: 69 [62-83]) from seven hospitals were retrospectively identified with 26 attempts at TRAE between 1/1/20 and 26/6/25. Definitions: index procedure (first successful attempt or definitive ERCP failure) or follow-up procedure. Technical success (TS): cannulation/intervention by ERCP. Clinical success (CS): resolution of cholangitis/jaundice. Baseline clinical data and technique modifications were recorded.  

There were 26 TRAEs (19 index/6 scheduled revisions/1 failed prior to index TRAE) in 19 patients. TS/patient during index TRAE was 13/19 (68.5%); one failed TRAE was salvaged at on a repeat attempt using double guidewire traction, following antergrade transpyloric rendezvous, with guidewire retrieval towards the EUS-GE through the LAMS. TS/procedure = 19/26 (73%), with 6 failed TRAE salvaged by EUS-BD. Failed TRAE incidence: 5 (70%) without papillary access, and 2 without cannulation. TS in follow-up TRAE was 6/6 (100%). CS was obtained in 100% of patients/procedures with TS. 

Biliary stent carriers and patients with prior GOO treated with LAMS predominated (Table). AE: 2 LAMS dislodgement (7.7%), one required surgery and another underwent laparotomy despite successful salvage and died of postoperative AEs. Dual guidewire traction effectively prevented LAMS dislodgment (0/13 vs 2/13). During follow-up, 2 transpapillary stent dysfunctions (15%), required convertion to EUS-BD. 

TRAE allows biliary drainage in anatomically challenging patient with native upper GI anatomy and CBGO, it is facilitated by a therapeutic gastroscope with dual guidewire traction, and is particularly suited for nonsurgical patients requiring revisions. This novel approach appears to avoid less invasive therapeutic options