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

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. We retrospectively analyzed data from patients with malignant biliary obstruction treated by EUS-HGS between 2002 and 2018 at a tertiary referral center. 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%). 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