What is the role of Endoscopic Ultrasonography (EUS) guided choledochoduodenostomy as an endoscopic management of ascending cholangitis in a patient with afferent limb syndrome?

From the Guidelines

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) is the recommended approach for managing ascending cholangitis in patients with afferent limb syndrome (ALS), as it provides a minimally invasive and effective solution with high technical and clinical success rates. ALS occurs following surgeries like Billroth II or Roux-en-Y reconstructions, where the afferent limb becomes obstructed, preventing access to the biliary system through conventional endoscopic retrograde cholangiopancreatography (ERCP) 1. In these challenging cases, EUS-CD provides a viable alternative by creating a direct conduit between the bile duct and duodenum, bypassing the obstructed afferent limb.

The procedure begins with administration of prophylactic antibiotics, typically a third-generation cephalosporin like ceftriaxone 2g IV or ciprofloxacin 400mg IV if penicillin-allergic. Under conscious sedation or general anesthesia, a linear echoendoscope is advanced to the duodenal bulb to visualize the dilated common bile duct. Using color Doppler to avoid vascular structures, a 19-gauge fine needle aspiration needle punctures the bile duct transduodenally. Bile is aspirated for confirmation and sent for culture. A guidewire is then passed through the needle into the bile duct, followed by tract dilation using a balloon dilator or cystotome. Finally, a fully covered self-expanding metal stent (8-10mm diameter, 4-6cm length) is deployed across the choledochoduodenal fistula.

Technical success rates exceed 90%, with clinical success in resolving cholangitis approaching 85-95% 1. Patients typically show rapid clinical improvement within 24-48 hours, with normalization of liver enzymes and resolution of fever and abdominal pain. Post-procedure care includes continued antibiotics based on culture results for 5-7 days, transitioning from IV to oral administration as clinical improvement occurs. Potential complications include bleeding (3-5%), bile leak (1-3%), stent migration (5-10%), and rarely perforation (<1%) 1. Follow-up includes liver function tests at 2 weeks and 3 months post-procedure, with stent exchange typically performed every 6-12 months to prevent occlusion.

Some key points to consider when performing EUS-CD include:

• The use of a 19-gauge EUS-FNA needle for duct puncture 1
• The use of a 0.035 inch or 0.025 inch guidewire with floppy tip to negotiate the bile duct 1
• The use of catheters, balloons or cystotomes for tract dilation 1
• The use of fully or partially covered metal stents for transluminal stenting 1
• The importance of multidisciplinary support, including interventional radiologist, surgeons and anaesthesiologist, to prevent and manage complications 1

Overall, EUS-CD offers significant advantages over percutaneous approaches, including higher patient comfort, reduced risk of external bile leakage, and avoidance of external drains. This technique has revolutionized management of biliary obstruction in surgically altered anatomy, providing an effective solution for the challenging scenario of ascending cholangitis in ALS patients.

From the Research

EUS-Guided Choledochoduodenostomy for Ascending Cholangitis in Afferent Limb Syndrome

• EUS-guided choledochoduodenostomy (EUS-CDS) is a viable endoscopic management option for ascending cholangitis in patients with afferent limb syndrome 2, 3, 4.
• The technical success rate of EUS-CDS is high, ranging from 90.8% to 92.8% 2, 5.
• Clinical success rates are also high, with rates of 91.6% to 94.8% reported in various studies 2, 5.
• The procedure is generally safe, with adverse event rates ranging from 10.2% to 17.5% 5, 6.
• EUS-CDS can be an effective alternative to percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in patients with failed or technically non-feasible ERCP 3, 4, 6.

Indications and Patient Selection

• EUS-CDS is indicated for patients with malignant distal biliary obstruction, including those with afferent limb syndrome 2, 5.
• Patients with moderate to severe cholangitis can also benefit from EUS-CDS, with high technical and clinical success rates reported 6.
• Patient selection should be based on individual factors, including the presence of altered anatomy, malignant tumors, and failed or technically non-feasible ERCP 3, 4.

Procedure-Related Outcomes

• The median stent patency time for EUS-CDS can range from 396 days to several months 2, 5.
• Re-intervention rates are generally low, with rates of 8.3% to 19.2% reported in various studies 2, 5.
• Adverse events, such as bleeding and bile leak, can occur but are often manageable with conservative treatment 5, 6.