Endoscopic ultrasound guided choledocoduodenostomy (CD) versus hepaticogastrostomies (HG) in distal malignant biliary obstruction: is it only a matter of expertise?

Aims Endoscopic retrograde drainage remains the first line treatment in distal malignant biliary obstructions (DMBO). However, recent series increasingly evaluate and propose EUS-CD as serious alternative, particularly in center with limited experience in EUS-HG. Indeed, randomized study demonstrated equivalent clinical efficacy and safety between ERCP and EUS-CD, without the risk of acute pancreatitis. However, in the case of duodenal stenosis, CD dysfunctions were observed, and EUS-HG seems the best option, but requires a higher level of expertise. We conducted this study to evaluate these two techniques in two centers with different level of expertise in EUS-HG.

Methods This is a retrospective observational study conducted in two French high-volume centers for biliary drainage. One has expertise in EUS-HG (EUS-HG group of patients), the other one having limited experience prioritizing EUS-CD (EUS-CD group). All patients analyzed underwent EUSBD for DMBO with jaundice, distributed in two groups of procedure: HG and CD. The main objective was to compare the clinical outcome of both techniques in managing DMBO, according to the level of expertise. The secondary objectives were to assess technical outcomes and identify other factors influencing these outcomes, particularly the impact of duodenal stenosis on biliary reintervention rate.

Results A total of 165 patients (137 in EUS-CD group; 38 in EUS-HG group) were included, 55.8% of men, with mean age 72.7±11.11 years old. The main origin of DMBO was pancreatic adenocarcinoma in 77%. Prior ERCP was attempted in 60% of patients. At baseline, both groups were comparable on age, gender, type of tumor and ASA score. The rate of duodenal stricture was higher in the EUS-HG group: 33% versus 70% (p<0.001), and the bilirubin level was higher in EUS-CD group: 280 vs 180 umol/l (p<0.001).

EUS-CD were performed using 6 or 8mm Axios stents (Boston, USA) and EUS-HG using 6 French cystotome and partially covered metal stents. Overall technical and clinical success rate were 98% and 93%, respectively, and similar whatever the procedure. The perioperative adverse event (AE) rate was 6%, essentially in EUS-CD, whereas the postoperative AEs rate was 12%, mostly in EUS-HG. During follow-up 27% of patient required duodenal stenting.

When comparing the groups after matching on age, gender, level of bilirubin and type of lesion, we observed in the EUS-CD group significantly more need for duodenal stenting, 68,4% vs. 45.9% (p<0.05), and more biliary reinterventions, 29.4% vs. 7.9% (p<0.05), respectively. No difference was observed in the survival time.

Conclusions This study suggests that EUS-CD and EUS-HG have similar technical and clinical outcomes according to the center’s expertise. However, in the case of duodenal stenosis, EUS-HG comes with less biliary obstruction, thus less reintervention rate. In these situations, expertise in EUS-HG is required.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
15 April 2024