EUS-Guided Choledochoduodenostomy for Distal Malignant Biliary Obstruction Using Electrocautery-Enhanced Lumen-Apposing Metal Stents: First US, Multicenter Experience.

Abstract

BACKGROUND AND AIMS:

EUS-guided biliary drainage has emerged as a technique to enable endobiliary drainage in failed ERCP. A newer model, lumen-apposing metal stents (LAMS), with a cautery-enhanced delivery system became available in the USA in late 2015. This cautery-tipped version may facilitate EUS-guided choledochoduodenostomy (EUS-CD), but data using this model are lacking.

METHODS:

We reviewed outcomes of attempted EUS-CD using cautery-enhanced LAMS from 6, US centers. The following data were collected: patient and procedure details, technical success, adverse events, clinical success (resolution of jaundice or improvement in bilirubin > 50%), and biliary re-interventions.

RESULTS:

EUS-CD was attempted in 67 patients (mean age 68.8) with malignant obstruction after failed ERCP between September 2015 and April 2018. EUS-CD was technically successful in 64 (95.5%). A plastic or metal stent was inserted through the lumen of the deployed LAMS in 50 of 64 (78.1%) patients to maintain a non-perpendicular LAMS axis into the bile duct. Adverse events occurred in 4 (6.3%) and included: abdominal pain (n = 2), peritonitis that responded to antibiotics (n = 1), and bleeding requiring transfusion (n = 1). Among 40 patients with follow-up of > 4 weeks, clinical success was achieved in 100%. Biliary re-interventions for obstruction were needed in 7(17.5%), in 3 of 6 (50.0%) that underwent EUS-CD with LAMS alone versus 4 of 34 (5%) with LAMS plus an axis-orienting stent (p = 0.02).

CONCLUSION:

EUS-CD using LAMS with cautery-enhanced delivery systems has high technical and clinical success rates, with a low rate of adverse events. Inserting an axis-orienting stent through the lumen of the LAMS may reduce the need for biliary re-interventions.

• Authors: Abdul H El Chafic, Janak N Shah, Chris Hamerski, Kenneth F Binmoeller, Shayan Irani, Theodore W James, Todd H Baron, Jose Nieto, Ricardo V Romero, John A Evans, Michel Kahaleh
• Journal: Digestive diseases and sciences (Dig Dis Sci) Vol. 64 Issue 11 Pg. 3321-3327 (11 2019) ISSN: 1573-2568 [Electronic] United States
• PMID: 31175495 (Publication Type: Journal Article, Multicenter Study)

Chemical References

• Metals

Topics

• Aged
• Aged, 80 and over
• Choledochostomy (methods)
• Cholestasis (diagnostic imaging, epidemiology, surgery)
• Duodenum (diagnostic imaging, surgery)
• Electrocoagulation (methods)
• Female
• Follow-Up Studies
• Humans
• Male
• Metals
• Middle Aged
• Retrospective Studies
• Stents
• Ultrasonography, Interventional (methods)
• United States (epidemiology)