Successful EUS-CDS for benign biliary obstruction after failed ERCP: a case series

Aims In cases of endoscopic retrograde cholangiopancreatography (ERCP) failure in distal malignant obstruction, endoscopic ultrasound-choledochoduodenostomy (EUS-CDS) is a safe and effective second-line option with benefits over percutaneous transhepatic biliary drainage (PTBD). We aim to demonstrate technical and clinical success of EUS-CDS in benign biliary obstruction as definitive treatment or to facilitate an ERCP rendezvous procedure.

Methods A restrospective audit was conducted over 3 years of patients who had EUS-CDS for benign biliary obstruction. Technical success was mesaured by successful placement of a lumen apposing metal stent (6x8mm LAMS, all cases hot AXIOS stent Boston Scientific, Marlborough MA, USA) between the common bile duct (CBD) and duodenum. Clinical success was measured by resolution of cholangitis and improvement in liver function tests.

Results Six patients aged 62 to 91 across two tertiary centres who had either one or two failed ERCPs, in the context of a difficult scope position or inaccessible ampulla within a diverticulum, were managed with EUS-CDS. Technical and clinical success was achieved in all six patients (all cases were stone disease after failed cannulation, with CBD size range 13mm-19mm). There was one incident of cholangitis post-procedurally in the first patient of the series, successfully treated with a second procedure to place a double pigtail stent (DPS) co-axially in the LAMS. The subsequent five patients had a DPS inserted co-axially through the LAMS at the time of the EUS-CDS, with no episodes of cholangitis. There were no other adverse events. In 3 of the patients, the LAMS was intentionally left in situ long-term due to significant age and co-morbidities with no issues at follow up at 6 months. The other three underwent successful ERCP and bile duct clearance using a rendezvous approach via the LAMS. The LAMS were removed uneventfully after stone clearance 6 weeks later.

Conclusions EUS-CDS has become standard technique for biliary drainage in malignant biliary obstruction after failed ERCP [Teoh, 2023]. EUS-CDS has advantages over PTBD owing to its improved technical and clinical success and safety profile [Shairaiha 2017]. Our case series suggests EUS-CDS is a safe, effective, second-line therapy where ERCP has failed for benign disease, as biliary drainage can be achieved during the same endoscopy session, and ERCP can then be completed using rendezvous technique via LAMS. Rendezvous via LAMS has several advantages over standard EUS-guided rendezvous procedures. These include reduced likelihood of losing the wire when being retrieved at ERCP, avoiding peri-ductal bile leak, and safer and easier manipulation of a guidewire in the antegrade direction across the papilla as a balloon catheters can pass easily across the LAMS into the CBD and duodenum. [1] [2]

EUS-CDS with LAMS should be considered after failed cannulation at ERCP in benign disease in carefully selected patients with sufficient extra-hepatic biliary dilatation. This approach also facilitates an easier ERCP rendezvous procedure. Placement of a co-axial DPS may prevent subsequent cholangitis in the context of stone disease.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Sharaiha R, Khan M. et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systemic review and meta-analysis. Gastrointestinal Endoscopy 2017; 85: 904-914
• 2 Teoh A, Napoleon B. et al. EUS-Guided Choledocho-duodenostomy using Lumen Apposing Stent Versus ERCP with Covered Metal Stents in Patients with Unresectable Malignant Distal Biliary Obstruction: A Multicentre Randomized Control Trial (DRA-MBO Trial). Gastroenterology 2023; 1-10

Publication History

Article published online:
15 April 2024