What are the indications for Endoscopic Ultrasonography (EUS) guided choledochoduodenostomy?

From the Guidelines

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) is primarily indicated for biliary drainage in patients with malignant distal biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) has failed or is not possible, as supported by the Asian EUS group consensus guidelines 1. The main indications for EUS-CD include:

• Unresectable pancreatic cancer
• Periampullary tumors
• Metastatic disease causing biliary obstruction where the papilla is inaccessible due to duodenal obstruction or altered surgical anatomy
• Failed cannulation during ERCP despite multiple attempts
• Patients who have undergone surgical procedures like Roux-en-Y gastric bypass that make conventional ERCP challenging This procedure creates a fistula between the bile duct and duodenum using specialized lumen-apposing metal stents under EUS guidance, with technical success rates of 90-95% and clinical success rates of 85-90% 1. The procedure requires expertise in therapeutic endoscopy and should be performed in centers with surgical backup, as emphasized by the Asian EUS group consensus guidelines 1. Potential complications include bleeding, bile leak, peritonitis, and stent migration, but EUS-CD offers advantages over percutaneous drainage, including single-session intervention, internal drainage avoiding external catheters, and potentially fewer adverse events 1. In terms of specific techniques, the use of a 19-gauge EUS-FNA needle for duct puncture and a 0.035 inch or 0.025 inch guidewire with floppy tip for negotiating the bile duct are recommended 1. Additionally, fully or partially covered metal stents are recommended for transluminal stenting, and the use of metal stents is recommended over plastic stents to reduce the risk of bile leak 1. Overall, EUS-CD is an important option for non-surgical biliary decompression in appropriate candidates, and its indications and techniques are supported by recent consensus guidelines and studies 1.

From the Research

EUS Choledochoduodenostomy Indications

• Malignant distal biliary obstruction after failed ERCP 2, 3, 4, 5
• Unresectable malignant distal bile duct obstruction 4
• Distal pancreatic adenocarcinoma 2, 3, 5
• Ampullary cancer 2
• Cholangiocarcinoma 2
• Patients at high risk of failed biliary cannulation 6

Procedure Details

• EUS-guided choledochoduodenostomy (EUS-CDS) with a lumen-apposing metal stent (LAMS) 2, 3, 4, 5
• Electrocautery-enhanced LAMS 3, 5
• AXIOS™ and Hot AXIOS™ delivery systems 4
• Technical success rates: 93.3% 2, 88.5% 3, 98.2% 4, 95.5% 5
• Clinical success rates: 96.2% 2, 100% 3, 96.4% 4, 100% 5

Adverse Events

• Adverse event rates: 10.5% 2, 3.8% 3, 7% 4, 6.3% 5
• Types of adverse events: abdominal pain, peritonitis, bleeding, duodenal perforation, cholangitis, stent migration, sump syndrome 2, 3, 4, 5