From the Guidelines
Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) is recommended as a viable alternative to ERCP for biliary drainage in patients with failed ERCP or altered anatomy, with a high level of agreement among experts 1. When considering EUS-CD, it is essential to prioritize the patient's morbidity, mortality, and quality of life. The procedure should be performed by experienced endoscopists with advanced EUS training in centers with multidisciplinary support, including interventional radiologists, surgeons, and anesthesiologists 1.
Key Considerations for EUS-CD
- A 19-gauge EUS-FNA needle is recommended for duct puncture, and a 0.035 inch or 0.025 inch guidewire with floppy tip should be used to negotiate the bile duct 1.
- Catheters, balloons, or cystotomes are recommended for tract dilation, while tract dilation with a precut papillotome is not recommended 1.
- Fully or partially covered metal stents are preferred over plastic stents due to better patency rates and fewer adverse events 1.
Procedure and Outcomes
The procedure involves identifying the dilated bile duct from the duodenal bulb, confirming position with aspiration and fluoroscopy, creating a fistula tract using electrocautery, dilating if necessary, and deploying the stent under endoscopic and fluoroscopic guidance.
- Technical success rates range from 90-95%, with clinical success rates of 85-90% 1.
- Potential complications include bleeding, bile leak, peritonitis, and stent migration, occurring in approximately 10-15% of cases.
Post-Procedure Care
Post-procedure care includes monitoring for complications, antibiotic prophylaxis, and follow-up imaging to assess stent patency.
- EUS-CD is particularly valuable for patients with altered surgical anatomy or duodenal obstruction where conventional ERCP access is impossible, providing effective long-term biliary drainage with acceptable complication rates 1.
From the Research
EUS Choledochoduodenostomy Guideline
Overview of EUS Choledochoduodenostomy
- EUS-guided choledochoduodenostomy (EUS-CDD) is a viable method for establishing biliary drainage in patients with malignant distal biliary obstruction (MDBO) 2.
- The procedure involves the use of electrocautery-enhanced lumen-apposing metal stents (EC-LAMS) to create a choledochoduodenostomy 2, 3, 4.
- EUS-CDD has been shown to be effective in patients where ERCP is not possible or has been unsuccessful 2, 5.
Technical and Clinical Success Rates
- Technical success rates for EUS-CDD have been reported to be between 88.5% and 97.7% 2, 3, 4.
- Clinical success rates, defined as a reduction in serum bilirubin to ≤50% of the original value within 14 days, have been reported to be between 94.8% and 100% 2, 3, 4.
- The use of an axis-orienting stent through the lumen of the LAMS may reduce the need for biliary re-interventions 4.
Adverse Events and Complications
- Adverse event rates for EUS-CDD have been reported to be between 6.3% and 17.5% 2, 3, 4.
- Common adverse events include abdominal pain, peritonitis, and bleeding 3, 4.
- Biliary reintervention after initial technical success may be required in some patients 2, 4.