Endoscopic ultrasound-guided choledochoduodenostomy results in fewer complications than percutaneous drainage following failed ERCP in malignant distal biliary obstruction

Abstract

Percutaneous transhepatic biliary drainage (PTBD) and endoscopic ultrasound-guided biliary drainage (EUS-BD), including choledochoduodenostomy (EUS-CDS), are alternative methods for biliary drainage in patients with distal malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Data on long-term outcomes, adverse events (AEs), and quality of life (QoL) after EUS-CDS and PTBD are limited. Therefore, we created a registry to evaluate the outcomes of both drainage procedures.Patients with distal MBO who underwent EUS-CDS or PTBD after unsuccessful ERCP were included in this multicenter investigator-initiated prospective registry over an 18-month inclusion period. Primary end points were procedure-related AEs and mortality within 90 days post-procedure. Secondary end points included technical and clinical success, reinterventions, hospital stay, and QoL.55 patients were included, with 12 patients undergoing PTBD (technical success 100%) and 43 patients EUS-CDS (technical success 97.7%). Prior to ERCP, 7/12 patients in the PTBD group and 12/43 patients in the EUS-CDS group opted for best supportive care. The 90-day mortality rate was 66.7% in the PTBD group and 20.9% in the EUS-CDS group (P = 0.005). Furthermore, 11/12 patients (91.7%) in the PTBD group and 19/43 (44.2%) in the EUS-CDS group developed one or more AEs (P = 0.004). The median post-procedural hospital stay was 4 days (interquartile range [IQR] 2-6) in the PTBD group vs. 1 day (IQR 1-2) in the EUS-CDS group (P = 0.001).When both modalities were available and technically feasible, gastroenterologists preferred EUS-CDS over PTBD. EUS-CDS seems to be associated with lower mortality and AE rates, shorter hospital admission, and fewer reinterventions, but a randomized controlled trial should confirm these observations.

Fig. 1

Images during endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) showing: a on EUS image, a lumen-apposing metal stent (LAMS) being inserted into the common bile duct (CBD); b on fluoroscopic image, a LAMS inserted between the duodenum and CBD, with a guidewire inserted through the LAMS toward the hilum of the liver for placement a plastic double-pigtail stent.

Fig. 2

Flowchart of patient inclusion. CBD, common bile duct; EUS-CDS, endoscopic ultrasound-guided choledochoduodenostomy; PTBD, percutaneous transhepatic biliary drainage.

Fig. 3

Kaplan–Meier curves of survival after percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) at: a 90 days (log rank [Mantel–Cox] test, P = 0.001); b 180 days ( P = 0.008).