The use of EUS-guided biliary drainage as rescue therapy after ERCP failure in distal malignant biliary obstruction: a single high volume center experience

Aims EUS-guided biliary drainage (EUS-BD) has been used as a rescue modality for relief of malignant biliary obstruction (MBO) after a failed endoscopic retrograde cholangio-pancreatography (ERCP). Recent randomized controlled trials (RCTs) and observational studies have been published to assess the suitability of EUS-BD as a first-line modality for achieving palliative BD. The aim of this study is to show the outcomes of our high-volume centre and the follow up of the patients.

Methods We conducted a single tertiary centre retrospective study of patients who underwent EUS-BD after ERCP drainage failure for MBO between February 2019 and May 2024. Patient demographics, procedural data and follow-up care were collected in a registry. Exitus or termination data retrieving was taken as end of follow up (min 3 days, max 50 months, median 2.24 months).

Results The study included 39 patients, of whom 37 underwent EUD BD after ERCP failure, while 2 patients were directly drained by EUS for bulbar stenosis which made the papilla unreachable. The majority of patients had pancreatic cancer, cholangiocarcinoma, or gallbladder malignancy. 34 patients underwent choledochoduodenostomy (EUS-CDS), while 5 patients, due to the impossibility of draining the common bile duct, underwent 'rescue' drainage of the gallbladder (EUS-GBD). For the 37 EUS-BD procedures done after ERCP, 26 were performed immediately after ERCP failure within the same session, while 11 were performed in a different session a few days later. EUS-CDS was performed through transduodenal access in 34 patients, while EUS-GBD was performed in 5 patients; in particular was performed cholecysto-gastrostomy in 3 patients cholecysto-duodenostomy in 2 patients. Technical success was achieved in 38 patients (97,4%). Clinical success (defined as a reduction in bilirubin values ​​of 50% in two weeks) was achieved in 32 out of 39 patients (82.1%). The rate of adverse events for EUS-BD was 21% (8/39): stent dislocation occurred in 5% (2/39), infection occurred in 10% (4/39) and stent occlusion occurred in 7% of cases following to EUS-BD (3/39). The need for endoscopic reintervention following EUS-BD in whole the follow up was 18% (7/39).

Conclusions In our series EUS-BD has high technical and clinical success rates and represents the method of choice in case of ERCP failure. Complication rates are aligned with the literature. Considering that patients undergoing EUS-BD had already failed transpapillary drainage and therefore presented an increased procedural difficulty and considering the high technical success of the procedure, it is desirable that this method could be included as a first line of treatment at least in selected patients with extensive papillary o duodenale neoplastic involvement.

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Artikel online veröffentlicht:
27. März 2025