Fistula dilation-free endoscopic ultrasound-guided choledochoduodenostomy using tubular dumbbell-shaped metal stent versus endoscopic retrograde cholangiopancreatography in first-line drainage for malignant distal biliary obstruction (with video).

BACKGROUND AND AIMS: EUS-guided choledochoduodenostomy (CDS) is a potential first-line drainage method for unresectable malignant distal biliary obstruction (UMDBO). However, lumen-apposing metal stents present difficulty in application for insufficient bile duct dilation, biliary wall compression, duodenobiliary reflux, and high cost. This study evaluated the utility of fistula dilation-free EUS-CDS with a tubular dumbbell-shaped metal stent (MS).

METHODS

In total, 224 patients with UMDBO met the inclusion criteria. Technical and clinical success, procedure time, and adverse events (AEs) including recurrent biliary obstruction (RBO) were compared between the EUS-CDS group and ERCP group who underwent transpapillary uncovered MS placement.

RESULTS

After one-to-one propensity score matching, 71 patients were included in each group. Technical success rates in the EUS and ERCP groups were 97.2% and 90.1%, respectively (P = .166). Clinical success was achieved in all technically successful cases in both groups. The median procedure time was significantly shorter in the EUS group than in the ERCP group (12 minutes vs 23 minutes, P < .001), whereas the rates of early and late AEs besides RBO were not significantly different between the groups. The EUS group demonstrated a significantly lower RBO incidence rate (13.0% vs 37.5%, respectively; P = .001) and significantly longer median time to RBO (not applicable vs 186 days, P = .008) compared with the ERCP group. Multivariate analysis revealed that EUS-CDS was associated with a significantly longer time to RBO.

CONCLUSIONS

Fistula dilation-free EUS-CDS using tubular MS with an appropriate antimigration function may be a useful option for primary drainage in patients with UMDBO.