What are the next steps if Endoscopic Retrograde Cholangiopancreatography (ERCP) fails?

Next Steps After Failed ERCP

When ERCP fails to achieve biliary drainage, EUS-guided biliary drainage (EUS-BD) should be the preferred next intervention over percutaneous transhepatic biliary drainage (PTBD) when adequate expertise is available. 1

Primary Recommendation: EUS-Guided Biliary Drainage

EUS-BD is strongly recommended as the first-line alternative after failed ERCP, based on the most recent 2025 EASL guidelines which provide a strong recommendation with strong consensus. 1 This approach offers several advantages:

• Higher clinical success rates compared to PTBD (OR 2.55,95% CI 1.63-4.56), meaning patients are more than twice as likely to achieve successful biliary decompression. 2
• Significantly fewer adverse events overall (OR 0.41,95% CI 0.29-0.59), representing a 59% reduction in complications. 2
• Lower rates of reintervention (OR 0.20,95% CI 0.10-0.38), meaning 80% fewer repeat procedures needed. 2
• Shorter hospital stays (mean difference of -4.89 days) and lower total treatment costs (mean difference of -$1,355). 2
• Less pain post-procedure (pain score 1.9 vs 4.1 for PTBD). 3

When to Choose EUS-BD vs PTBD

Choose EUS-BD when:

• Distal malignant biliary obstruction is present (most common indication). 1
• Perihilar obstruction classified as Bismuth types I and II. 1
• Expertise is available at your institution—this procedure requires experienced endoscopists trained in interventional EUS. 1
• Patient has coagulopathy (INR >2.0 or platelets <60K), as EUS-BD avoids liver capsule violation. 1
• Moderate to massive ascites is present, which is a relative contraindication for PTBD. 1

Choose PTBD when:

• EUS-BD has failed or is not available—PTBD remains a valuable backup option. 1
• Perihilar obstruction classified as Bismuth types III and IV, where percutaneous or combined endoscopic/percutaneous drainage may be preferred. 1
• EUS expertise is not available at your facility. 1

Critical Timing Considerations

For Acute Cholangitis:

• Biliary drainage must be achieved within 72 hours of presentation for patients with cholangitis or biliary obstruction. 1
• For severe sepsis or deteriorating patients, drainage should occur within 24 hours. 1
• If EUS-BD or repeat ERCP cannot be performed urgently, proceed directly to PTBD rather than delay drainage. 1

Technical Success Rates

Both approaches have similar technical success rates (approximately 91-98%), but differ significantly in clinical outcomes:

• EUS-BD technical success: 93-98%. 4, 3, 5
• PTBD technical success: 90-92%. 6, 3
• EUS-BD is the sole independent predictor of clinical success and long-term resolution (OR 21.8). 3

Important Caveats and Pitfalls

EUS-BD Considerations:

• Should only be performed by experienced endoscopists in tertiary care centers—serious adverse events and rare fatalities have been reported even in expert hands. 1
• Learning curve is significant—morbidity decreases substantially with experience (5 of 6 procedure-related deaths occurred in the first 50 cases in one series). 5
• Major complications occur in approximately 10-12% of cases, including bile leakage, sepsis, and bleeding. 5

PTBD Considerations:

• Bleeding risk is approximately 2.5% overall, but higher with coagulopathy—PTBD is contraindicated if coagulopathy cannot be corrected. 1
• Requires significantly more reinterventions (mean 4.9 vs 1.3 for EUS-BD). 3
• Late adverse events occur in 54% of patients (vs 6.6% for EUS-BD). 3
• Catheter-related complications and poor quality of life due to external drainage are common. 3

Surgical Drainage

Open surgical drainage should only be used when both endoscopic and percutaneous approaches have failed, are contraindicated, or are unavailable. 1 Emergency surgery for severe cholangitis carries high mortality rates and is rarely indicated in the modern era. 1

Algorithm Summary

1. ERCP fails → Assess for EUS-BD expertise availability
2. If EUS-BD available → Proceed with EUS-guided biliary drainage (preferred)
3. If EUS-BD unavailable or fails → Proceed with PTBD
4. If both fail or contraindicated → Consider surgical drainage
5. For acute cholangitis → Ensure drainage within 72 hours (24 hours if severe sepsis)