Original article
Clinical endoscopy
Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach

https://doi.org/10.1016/j.gie.2014.09.054Get rights and content

Background

A single session of EUS-guided biliary drainage (EUS-BD) may be a viable alternative to ERCP in patients with malignant distal common bile duct (CBD) obstruction. There is no study comparing EUS-BD and ERCP for the relief of distal malignant biliary obstruction.

Objective

To compare the outcomes of self-expandable metal stent (SEMS) placement for malignant distal biliary obstruction by using ERCP and EUS-BD.

Study Design

Multicenter, retrospective analysis.

Setting

Tertiary referral centers.

Patients

Patients with malignant distal CBD obstruction requiring SEMS placement.

Interventions

Patients in the EUS-BD group underwent EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade (EUS-AG) procedures after 1 or more failed ERCP attempts. Patients in the ERCP group underwent retrograde SEMS placement.

Main Outcome Measurements

Composite success (the ability to complete the intended therapeutic procedure in a single session and resulting in a greater than 50% decrease in bilirubin over 2 weeks).

Results

The study included 208 patients, 104 treated with ERCP and 104 treated with EUS-BD (68 EUS-CDS, 36 EUS-AG). SEMS placement was successful in 98 patients in the ERCP group and 97 in the EUS-BD group (94.23% vs 93.26%, P = 1.00). The frequency of adverse events in the ERCP and EUS-BD groups was 8.65% and 8.65%, respectively. Postprocedure pancreatitis rates were higher in the ERCP group (4.8% vs 0, P = .059). The mean procedure times in the ERCP and EUS-BD groups were similar (30.10 and 35.95 minutes, P = .05).

Limitations

Retrospective analysis.

Conclusions

In patients with malignant distal CBD obstruction requiring SEMS placement, the short-term outcome of EUS-BD is comparable to that of ERCP.

Section snippets

Patients and methods

This was an international, multicenter, retrospective analysis that included 7 centers. The eligibility criterion for participating centers was the availability of expertise in both therapeutic ERCP and EUS-BD. The participating investigators had a cumulative experience of 82,900 therapeutic ERCPs (median experience of 4100 procedures, range 2110-41,300) over a median of 10 years (range 4-22 years), and 656 EUS-BD procedures (median of 58 procedures, range 31-246) over a median of 5 years

Results

There were 208 patients with malignant distal CBD obstruction (104 each in the ERCP and EUS-BD groups). SEMS placement was technically successful in 195 patients (93.75%) with clinical success in 188 (90.38%). Adverse events were encountered in 18 patients (8.65%).

Discussion

This retrospective study suggests that EUS-BD is as safe and effective as ERCP for SEMS placement in malignant distal CBD obstruction in the short term. Although all EUS-BD patients had 1 or more previous failed ERCP attempts, and a higher proportion of these patients had DS, the cohorts were well matched for demographic and clinical characteristics. Despite previous failed interventions and anatomic limitations from luminal structuring, the technical and clinical outcomes of the EUS-BD cohort

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this article.

    See CME section; p. 976.

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