TOPLINE:

In patients with malignant distal biliary obstruction, endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) reduced the rate of postprocedural pancreatitis compared with endoscopic retrograde cholangiopancreatography (ERCP). Additionally, rates of technical success were higher, and procedure times were shorter with EUS-CDS.

METHODOLOGY:

• Postprocedural pancreatitis is the most common adverse event associated with ERCP. EUS-CDS has emerged as an alternative approach, creating a biliary bypass away from the papillary region and pancreatic duct, theoretically reducing the risk for postprocedural pancreatitis.
• Researchers conducted a multicenter clinical trial in Italy from 2021 to 2023 to evaluate whether EUS-CDS lowers the risk for postprocedural pancreatitis in patients with malignant distal biliary obstruction compared with ERCP.
• They included patients (aged ≥ 18 years) with obstructive jaundice, elevated bilirubin levels (at least three times the upper limit of normal), and a dilated extrahepatic bile duct (≥ 15 mm) and randomly assigned them to undergo either EUS-CDS or ERCP for primary biliary drainage.
• The primary outcome was the rate of postprocedural acute pancreatitis. Secondary outcomes were technical success (defined as successful biliary drainage through stent placement), clinical success (decrease in bilirubin levels to 50% of baseline levels or < 3 mg/dL within 2 weeks), and the 6-month stent patency rate.

TAKEAWAY:

• Among 220 patients (mean age, 73.28 years; 45.5% women) included in the study, 111 patients underwent EUS-CDS and 109 underwent ERCP.
• At the 6-month follow-up assessment, patients undergoing EUS-CDS had a 75% reduced risk for postprocedural pancreatitis compared with those undergoing ERCP (P < .05), with one episode of postprocedural pancreatitis prevented for every 18 patients treated.
• EUS-CDS achieved higher technical success rates than ERCP (94.6% vs 78.9%; P < .01) and had shorter mean procedure times (13.5 vs 24.7 minutes; P < .01).
• Overall procedure-related adverse event rates, clinical success rates, and 6-month mortality rates did not differ significantly between the EUS-CDS and ERCP groups.

IN PRACTICE:

“EUS-CDS with LAMS [lumen-apposing metal stent] is superior to ERCP with SEMS [self-expandable metal stent] placement in reducing the risk of postprocedural acute pancreatitis,” the authors of the study wrote.

“Additionally, EUS-CDS demonstrates favorable technical efficiency and preserved clinical efficacy. These results support the potential role of EUS-CDS as a primary approach in selected patients with dilated common bile ducts (≥ 15 mm),” they added.

SOURCE:

This study was led by Andrea Anderloni, MD, PhD, Fondazione IRCCS Policlinico San Matteo, Gastroenterology and Digestive Endoscopy Unit in Pavia, Italy. It was published online in Gastroenterology.

LIMITATIONS:

As operator blinding was not feasible in this interventional trial, performance bias may have been introduced. An imbalance in concomitant EUS‑guided tissue acquisition — with the procedure performed more frequently in the ERCP group — could also have influenced outcomes. The study’s sample size limited statistical inferences regarding specific features that might have enhanced outcomes with either approach.

DISCLOSURES:

This study received an unrestricted grant from Boston Scientific. Several authors disclosed receiving payments or honoraria for lectures, presentations, manuscript writing, educational events, or participation in speakers’ bureaus from various companies, including Boston Scientific, Olympus, and AstraZeneca.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.