Endosonography-guided choledochoduodenostomy versus a transphincteric approach

We read with interest the article by Kawakubo et al. on endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) versus transpapillary stenting (TPS) for distal biliary obstruction [1]. The authors studied a cohort of 82 patients and compared 26 patients who underwent EUS-CDS with 56 patients who underwent TPS. They found that both groups had similar rates of clinical success (96.2 % vs. 98.2 %), 1-year re-intervention (16.6 % vs. 13.6 %), and adverse events (26.9 % vs. 35.7 %). However, the EUS-CDS group in this study was noted to have shorter procedure times with no risk of pancreatitis.

We think that this study is a good example of an instinctive desire to learn whether a new technique can challenge the conventional old one. The study authors carried out this comparison between EUS-CDS and TPS retrospectively wıth a limited number of patients and, on the basis of the data noted above, they proposed EUS-CDS as a first-line treatment modality for patients with distal malignant biliary obstruction. However, like many readers of this article we have some concerns about their conclusion regarding the replacement of TPS by EUS-CDS in patients with malignant distal biliary obstruction.

First, EUS-guided drainage procedures have a learning curve in relation to technical and clinical success and adverse events rates. One of the reports on EUS-guided biliary drainage procedures, including EUS-CDS, clearly underlines the negative effects of the learning period [2]. Our understanding of the text is that Kawakubo et al. started to do EUS-CDS from May 2012 as first-line therapy in 26 patients. It is very surprising that they did EUS-CDS without being compromised by this learning curve effect, since they had nearly 100 % clinical success and minimal or no major adverse events.

Second, the authors also mentioned that patients who underwent EUS-CDS had significantly shorter procedure times and pancreatitis rates than those of the TPS group. They noted in the text that EUS-CDS was performed by expert endosonographers, but they did not report such an advantage of experience in the endoscopists performing TPS. In ERCP-guided TPS, operator experience is a well-known determining factor both for procedure duration and for risk of post-ERCP pancreatitis. We are also aware of another study that reported nearly identical procedure times for EUS-CDS and TPS in patients with distal biliary malignancy [3]. In that study, both procedures were performed by endoscopists who were highly experienced in EUS-guided biliary drainage and in TPS with ERCP.

Third, although the difference was noted to be insignificant, the rate of moderate complications in the present study (including 2 liver abscesses and 1 biliary peritonitis) was apparently higher in the EUS-CDS group than in the TPS group (19 % vs 7.5 %, respectively).

Furthermore, the authors did not provide any data in this study about the cost – effectiveness of the EUS-CDS approach in their patients.

We believe that EUS-guided biliary drainage is an efficient technique, but is known to be associated with significant morbidity that seems to decrease with progress along the learning curve. Although the results of prospective randomized studies would seem to be more reliable for comparing EUS-guided biliary drainage with TPS, the ERCP-guided approach for patients with malignant distal biliary obstruction holds its position as the first-choice therapeutic modality in the real world. For the time being, the EUS-guided approach should be performed in selected patients after failure of ERCP attempts.

• References

• 1 Kawakubo K, Kawakami H, Kuwatani M et al. Endoscopic ultrasound-guided choledochoduodenostomy vs. transpapillary stenting for distal biliary obstruction. Endoscopy 2016; 48: 164-169
• 2 Poincloux L, Rouquette O, Buc E et al. Endoscopic ultrasound-guided biliary drainage after failed ERCP: cumulative experience of 101 procedures at a single center. Endoscopy 2015; 47: 794-801
• 3 Dhir V, Itoi T, Khashab MA et al. Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach. Gastrointest Endosc 2015; 81: 913-923