From the Guidelines
EUS-guided choledochoduodenostomy (EUS-CD) should be used as an alternative biliary drainage technique when endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible in patients with malignant distal biliary obstruction, particularly in those with surgically altered anatomy or duodenal obstruction. This procedure is typically indicated in cases where patients have failed ERCP or have altered postoperative anatomy, as stated in the consensus guidelines by the Asian EUS group 1. The guidelines recommend EUS-BD as the procedure of choice for biliary drainage in patients with failed ERCP if expertise is available, with a high level of evidence.
Indications for EUS-CD
- Failed ERCP
- Altered postoperative anatomy
- Duodenal obstruction
- Inaccessible papilla or unsuccessful cannulation attempts
Procedure Details
EUS-CD involves creating a fistula between the bile duct and duodenum under endoscopic ultrasound guidance, followed by placement of a stent to maintain patency. The procedure requires specialized expertise and equipment, including a linear echoendoscope, fine needle aspiration needles, guidewires, dilators, and dedicated biliary stents (preferably lumen-apposing metal stents) 1.
Potential Complications
Potential complications include bleeding, bile leak, peritonitis, and stent migration, so patients should be monitored closely post-procedure 1. However, with improved outcomes and experience, adverse event rates have been reported as low as 11% 1.
Technical Success Rates
EUS-CD is particularly valuable in palliative settings for patients with pancreatic cancer or other malignancies causing biliary obstruction, offering effective biliary drainage with technical success rates of 90-95% when performed by experienced endoscopists 1.
From the Research
Indications for EUS-Guided Choledochoduodenostomy
EUS-guided choledochoduodenostomy is considered in the following situations:
- Unresectable periampullary cancer with obstructive jaundice and duodenal obstruction 2
- Failed endoscopic retrograde cholangiopancreatography (ERCP) 3, 4
- Malignant biliary obstruction with failed ERCP 5
- Unresectable pancreatic cancer with obstructive jaundice when ERCP is unsuccessful 4
Technical Success and Clinical Efficacy
The technical success rate of EUS-guided choledochoduodenostomy is high, ranging from 93.5% to 100% 2, 5 The clinical efficacy of the procedure is also high, with improvement in obstructive jaundice in all cases 2, 3, 6, 4
Adverse Events
Adverse events associated with EUS-guided choledochoduodenostomy include:
Stent Patency
The average stent patency is around 211.8 days 6 Stent exchange is successful in most cases, with one failure due to tumor invasion to the choledochoduodenal fistula 6