EUS-guided biliary drainage an option for unresectable malignant biliary obstruction

Endoscopic ultrasound (EUS)–guided choledocho-doudenostomy (ECDS) can be an option for primary biliary drainage in patients with unresectable malignant distal biliary obstruction (MDBO), and may be preferred when endoscopic retrograde cholangiopancreatography (ERCP) is anticipated to be difficult, according to an international randomized controlled trial (RCT) led by researchers from the Chinese University of Hong Kong (CUHK).

“We introduced ECDS in Hong Kong some 10 years ago and are one of the pioneers of this almost noninvasive technique in the Asia-Pacific region. This technique was first applied to patients at the Prince of Wales Hospital and is now increasingly adopted in public hospitals in Hong Kong,” said Dr Shannon Chan of the Department of Surgery, CUHK. “EUS-guided stent deployment in ECDS allows direct connection between the bile duct and duodenum, which is similar to surgical bypass, and can reduce tumour ingrowth into the stent.”

The RCT, conducted in 10 high-volume centres in Hong Kong, France, Belgium, Denmark, Italy, Thailand and Australia, included 155 patients admitted between January 2017 and February 2021 for obstructive jaundice due to unresectable MDBO. The patients were randomized to undergo primary ECDS with lumen apposing metal stent (n=79; mean age, 75.1 years; male, n=32; pancreatic cancer diagnosis, n=76) or ERCP with partially covered self-expanding metal stent (n=76; mean age, 72.1 years; male, n=41; pancreatic cancer diagnosis, n=73). [Gastroenterology 2023;165:473-482.e2]

“The primary outcome of 1-year stent patency rate was high, at 91.1 percent in the ECDS group vs 88.1 percent in the ERCP group, with no significant between-group difference [p=0.052],” reported Professor Anthony Teoh of the Department of Surgery, CUHK.

One-year reintervention rates were similar between the ECDS and ERCP groups (11.3 percent vs 12.7 percent; p=0.48), with tumour overgrowth being the most common reason (3.8 percent vs 9.2 percent).

“Technical success [defined as ability to access and drain the common bile duct by placement of a stent] was achieved by significantly more patients in the ECDS vs ERCP group, with rates of 96.2 percent vs 76.3 percent [p<0.001],” said Teoh.

Rates of clinical success, defined as >30 percent drop in bilirubin levels within 5 days, were similar between the ECDS and ERCP groups (93.7 percent vs 90.8 percent; p=0.559).

“ECDS was also associated with significantly shorter median procedural time than ERCP, at 10 minutes vs 25 minutes [p<0.001],” Teoh noted. “Similar rates of 30-day adverse events [16.5 percent vs 17.1 percent for ERCP; p=1] and 30-day mortality [5.1 percent vs 7.9 percent; p=0.53] were reported between the two groups.”

“These results suggest that both ECDS and ERCP could be options for primary biliary drainage in patients with unresectable MDBO. As ECDS is associated with a higher technical success rate and shorter procedural time, it is preferred when difficult ERCPs are anticipated, such as in patients with oedema and friability in the second portion of the duodenum, malignant infiltration of the ampulla, and duodenal obstruction,” Teoh suggested.