Endoscopic ultrasound-guided choledochoduodenostomy: is the rate of stent dysfunction underestimated?

In this issue of Endoscopy, Fritzsche et al. from Amsterdam present the results of their prospective study on endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) for the primary drainage of malignant distal biliary obstruction (MDBO) (SCORPION-p study) [1]. The authors reported very high technical and clinical success rates of 91% and 86%, respectively, which are comparable to those reported in the literature [2]. In a recent multicenter series with EUS-CD performed in patients with endoscopic retrograde cholangiopancreatography (ERCP) failure, the results were the same, with 92% and 86% technical and clinical success rates, respectively [3]. These rates were also confirmed in another systematic review and meta-analysis including lumen-apposing metal stents (LAMS) and self-expandable metal stents (SEMS), with technical and clinical success rates of 94.8% and 93.6%, respectively [4]. Therefore, the efficacy of EUS-CD is about 90% or more in the literature and the discussion should be focused on adverse events or recurrent jaundice, which have been reported to be 5.6% and 11.3%, respectively [5].

In the Fritzsche et al. study, the authors did not report immediate procedural or periprocedural adverse events, showing that in expert centers, EUS-CD could be safe. In contrast, the authors found an unusually high rate of stent dysfunction (55%) when they followed the patients for at least 6 months, this rate being much higher than that reported in the literature (6%–37%). This is probably the feeling of many operators in real life. Thus, we should be mindful of the risk factors for stent dysfunction as well as strategies to prevent stent dysfunction.

“The high rate of stent dysfunction reported in this study should prompt the careful follow-up of patients, limiting the indication of EUS-CD to patients with a common bile duct diameter of >15 mm, and avoiding cases of duodenal invasion.”

The frequency, risk factors, classification, and prevention of stent dysfunction reported in the literature are controversial [2] [6] [7]. The results of 155 studies on EUS-guided biliary drainage found rates of stent migration or occlusion of 1.7% and 11%, respectively [6]. The reintervention rate was 16.2%, which is perhaps more representative of the overall rate of stent dysfunction [6]. Risk factors were assessed in a prospective single-center study in patients undergoing EUS-CD, more than 75% of whom had MDBO [7]. Overall, 16.3% of patients presented biliary obstruction during a mean follow-up of 242 days. The multivariate analysis showed two significant risk factors associated with long-term stent obstruction: a common bile duct (CBD) diameter <15 mm and presence of a duodenal stent [7]. The Leuven–Amsterdam–Milan study also assessed the characteristics, rate, and risk factors for choledochoduodenostomy stent dysfunction [2]. In this study, 93 patients with MDBO were followed, with 6-mm stents implanted in two-thirds of the patients. Stent dysfunction occurred in 31.8% of patients within a mean of 166 days, which is the closest result to the 55% rate identified in the Fritzsche et al. study [1]. Almost all stent dysfunctions were successfully managed endoscopically (96%) [2]. The only predictive risk factor in this study was duodenal invasion, and the dysfunction-free survival was 75% at 6 months and 52% at 12 months [2]. In the Fritzsche et al. study, stent dysfunction occurred in 11/20 patients (55%) within 6 months and the median dysfunction-free survival was 140 days, stent dysfunction clearly occurring earlier in this series. The Fritzsche et al. study is probably more clinically relevant, as the diagnosis of stent dysfunction was a prospective combination of cholangitis and/or cholestasis or jaundice [1]. All the stents used were 6 mm in diameter, which may also be a risk factor for earlier stent dysfunction. It seems that stents with larger diameters could be associated with a decreased rate of reintervention (despite the same technical success) compared with stent diameters of 8 or 10 mm [8].

Strategies aimed at preventing stent dysfunction remain under debate. Many series have reported that previous duodenal stenting or duodenal stenosis is associated with a higher rate of stent dysfunction [2] [7] [9]. The first recommendation should be to avoid any EUS-CD in cases of duodenal invasion. The present study included only MDBO without clinically relevant gastric outlet obstruction but the stent dysfunction rate was high [1]. A prospective study reported that relatively weak dilation of the CBD is a risk factor for complications: for CBD diameters <12mm, EUS-CD should be avoided; between 12–15 mm, EUS-CD should be performed only by an expert; and a CBD diameter >15 mm should be the best indication for a non-expert [10]. Although the Fritzsche et al. study did not report stent misdeployment or dislodgment, such complication is severe, reaching a rate of 5.8% in a recent study [11]. In case of misdeployment, there is no consensus about rescue techniques, but one of the main options could be to use a preloaded guided wire in order to switch to the stent-in-stent technique in cases of misdeployment, limiting further surgical management to a rate of 10.3% [11].

In addition to avoiding risk factors such as gastric outlet obstruction or insufficient dilation of the CBD, some authors have proposed inserting a double-pigtail stent within the LAMS in order to avoid biliary mucosal intussusception or food impaction [12]. A retrospective multicenter study assessing the insertion of a double-pigtail stent throughout the LAMS showed similar results regarding clinical efficacy and adverse events, but the rate of recurrent biliary obstruction yielded favorable results (13.6% vs. 23.5%) [12]. A randomized controlled trial on this topic is currently under way in Spain, the BAMPI study [13].

To conclude, in the context of the current literature on the efficiency and safety of EUS-CD, it is acceptable to propose EUS-CD as the first-line approach for the management of MDBO according to the expertise of the center, but the important risk for stent dysfunction must be considered. In this perspective, two recent randomized series showed noninferior or better results when comparing EUS-CD with ERCP [14] [15]. The high rate of stent dysfunction reported in the Fritzsche et al. study should prompt the careful follow-up of patients, limiting the indication of EUS-CD to patients with a CBD diameter of >15 mm, and avoiding cases of duodenal invasion. Insertion of a double-pigtail stent inside the LAMS should delay any stent dysfunction.

Publication History

Article published online:
14 November 2023

• References

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