What is the best approach for an 85-year-old female patient with a suspected biliary malignancy, specifically cholangiocarcinoma, and a distal common bile duct (CBD) mass, who had a failed initial Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure and has a pancreatic duct stent, if a repeat ERCP is planned?

Management of Failed ERCP in Suspected Cholangiocarcinoma

EUS-guided choledochoduodenostomy (EUS-CDS) is the preferred next step if the repeat ERCP fails, and you should coordinate with the HPB service now to ensure availability of an experienced EUS-BD operator for the planned repeat ERCP date. 1

Immediate Communication Strategy

You should reply to the GI provider now to:

• Confirm EUS-CDS capability is available if repeat ERCP fails
• Coordinate timing so an experienced EUS-BD operator is available during the repeat ERCP session
• Discuss tissue acquisition strategy (see below)

Do not delay this coordination—waiting until after a second ERCP failure to arrange EUS-BD access creates unnecessary delays in drainage and increases risk of cholangitis. 1

Evidence Supporting EUS-Guided Biliary Drainage After Failed ERCP

When ERCP fails in malignant biliary obstruction, EUS-guided biliary drainage (EUS-BD) should be preferred over percutaneous transhepatic biliary drainage (PTBD) when adequate expertise is available. 1

The 2025 EASL guidelines provide strong evidence that:

• EUS-BD achieves better clinical success rates than PTBD 1
• Lower adverse event rates compared to PTBD 1
• Lower rates of re-intervention due to decreased stent/catheter dysfunction 1
• For distal CBD masses specifically, EUS-BD may perform similarly or better than ERCP as first-line intervention 1

Critical Considerations for This 85-Year-Old Patient

Pancreatic Duct Stent Management

The inadvertent pancreatic duct stent placement requires attention:

• This stent should be removed or exchanged during the repeat ERCP to prevent long-term ductal injury 2
• If left in place, it increases risk of stent occlusion and recurrent pancreatitis 2

Tissue Acquisition Strategy

You must discuss with the HPB surgeon before performing EUS-FNA of the primary tumor, as there is a theoretical risk of needle tract seeding that could affect resectability assessment. 1

However, for this 85-year-old patient:

• Age and suspected cholangiocarcinoma make surgical resection less likely
• If the patient is not a surgical candidate, EUS-FNA can be performed safely during the same session as EUS-BD 1
• EUS-guided sampling has 89% diagnostic sensitivity and 87% accuracy for suspected cholangiocarcinoma 1

During the repeat ERCP, combine brush cytology and forceps biopsy—this combination significantly improves diagnostic yield over brushing alone (64.7% vs 29.4%). 1

Repeat ERCP Success Rates

The decision to attempt repeat ERCP is well-supported:

• Second-attempt ERCP at referral centers achieves 96% cannulation success 3, 4
• Advanced cannulation techniques are used in 41% of cases 4
• Anatomic abnormalities contributing to initial failure are present in 27% 4

The high success rate of repeat ERCP (96%) justifies the planned second attempt, but having EUS-BD capability immediately available is essential. 3, 4

Optimal Drainage Strategy for Distal CBD Mass

For this distal cholangiocarcinoma, self-expanding metal stents (SEMS) are strongly preferred over plastic stents if the patient has advanced/unresectable disease. 1

SEMS provide:

• Higher therapeutic success rates 1
• Lower 30-day occlusion rates 1
• Lower long-term occlusion rates 1
• Reduced need for re-interventions 1

Procedural Planning Algorithm

1. Before repeat ERCP: Confirm with HPB surgery whether patient is a surgical candidate

   • If resectable: avoid EUS-FNA of primary tumor 1
   • If unresectable: plan combined EUS-FNA + EUS-BD if ERCP fails 1

2. During repeat ERCP:

   • Remove/exchange pancreatic duct stent 2
   • Perform both brush cytology AND forceps biopsy 1
   • Place SEMS if successful cannulation achieved 1

3. If repeat ERCP fails:

   • Immediately proceed to EUS-CDS (same session if operator available) 1
   • Perform EUS-FNA for tissue diagnosis if not surgical candidate 1
   • Consider sampling visible lymph nodes for staging 1

Complication Risk Considerations

At age 85, minimizing repeat procedures is paramount:

• ERCP complication rate is 10.8% overall, with 1.8% severe complications 5
• EUS-BD has lower adverse event rates than PTBD 1
• Having EUS-BD capability available during the repeat ERCP session avoids need for a third procedure or PTBD placement 1

Key Pitfall to Avoid

Do not wait until after the second ERCP fails to arrange EUS-BD capability—this creates delays in drainage, increases cholangitis risk, and may necessitate emergency PTBD placement with its higher complication profile. 1