International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs. choledochoduodenostomy approaches

Abstract

Background and study aims: Endoscopic ultrasound-guided biliary drainage (EUS-BD) can be performed entirely transgastrically (hepatogastrostomy/EUS-HG) or transduodenally (choledochoduodenostomy/EUS-CDS). It is unknown how both techniques compare. The aims of this study were to compare efficacy and safety of both techniques and identify predictors of adverse events. Patients and methods: Consecutive jaundiced patients with distal malignant biliary obstruction who underwent EUS-BD at multiple international centers were included. Technical/clinical success, adverse events, stent complications, and survival were assessed. Results: A total of 121 patients underwent EUS-BD (CDS 60, HG 61). Technical success was achieved in 112 (92.56 %) patients (EUS-CDS 93.3 %, EUS-HG 91.8 %, P = 0.75). Clinical success was attained in 85.5 % of patients who underwent EUS-CDS group as compared to 82.1 % of patients who underwent EUS-HG (P = 0.64). Adverse events occurred more commonly in the EUS-HG group (19.67 % vs. 13.3 %, P = 0.37). Both plastic stenting (OR 4.95, 95 %CI 1.41 – 17.38, P = 0.01) and use of non-coaxial electrocautery (OR 3.95, 95 %CI 1.16 – 13.40, P = 0.03) were independently associated with adverse events. Length of hospital stay was significantly shorter in the CDS group (5.6 days vs. 12.7 days, P < 0.001). Mean follow-up duration was 151 ± 159 days. The 1-year stent patency probability was greater in the EUS-CDS group [0.98 (95 %CI 0.76 – 0.96) vs 0.60 (95 %CI 0.35 – 0.78)] but overall patency was not significantly different. There was no difference in median survival times between the groups (P = 0.36) Conclusions: Both EUS-CDS and EUS-HG are effective and safe techniques for the treatment of distal biliary obstruction after failed ERCP. However, CDS is associated with shorter hospital stay, improved stent patency, and fewer procedure- and stent-related complications. Metallic stents should be placed whenever feasible and non-coaxial electrocautery should be avoided when possible as plastic stenting and non-coaxial electrocautery were independently associated with occurrence of adverse events.

Endoscopic Ultrasound-Guided Biliary Drainage in Two Patients with Difficult Biliary Access

“…Hepatogastric drainage was associated with a higher risk of complications in a recent review [9] and in a recent multicenter study, where choledochoduodenostomy was also associated with shorter inpatient stay and improved stent patency [10]. On the other hand, a comparative study between the two tech-niques showed a significantly longer stent patency with hepaticogastrostomy and a lower risk of adverse events [11].…”

Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography‐guided biliary drainage: 2018

“…However, these stents are associated with risks of bile leakage, fistula, and stent migration [86]. Therefore, covered SEMSs have been used recently [24,57,60,62,64,85,94,[96][97][98]. In a retrospective analysis of 121 EUS-BD [94], the use of a plastic stent was significantly associated with adverse event rate (OR 4.95, P = 0.01).…”

“…Therefore, covered SEMSs have been used recently [24,57,60,62,64,85,94,[96][97][98]. In a retrospective analysis of 121 EUS-BD [94], the use of a plastic stent was significantly associated with adverse event rate (OR 4.95, P = 0.01). Although a dedicated plastic stent for EUS-BD has been developed, the rate of adverse events was 17.4% (three mild pain and one moderate bleeding) in a prospective feasibility study [67], which appeared comparable to the conventional plastic stents.…”

The future of ERCP

“…The reasons, of course, are obvious and include improved noninvasive imaging (computed tomography and magnetic resonance imaging/magnetic resonance cholangiopancreatography), and the predominant role endoscopic ultrasound (EUS) has come to play in defining pancreaticobiliary lesions because of its relative safety and its superiority over ERCP in tissue acquisition 4 5 6 7 8. Moreover, the rate of growth of therapeutic procedures has been blunted not only by the ability of EUS to access and apply therapy to the pancreas, bile duct, and gallbladder 9 10 11 12 13 but also as a consequence of studies showing no benefit for ERCP in select situations. As such, we no longer routinely undertake biliary drainage in jaundiced patients undergoing pancreatic surgery for malignancy 14.…”