Surgical Endoscopy

, Volume 30, Issue 11, pp 5002–5008 | Cite as

EUS-guided choledochoduodenostomy for malignant distal biliary obstruction using a lumen-apposing fully covered metal stent after failed ERCP

  • Rastislav KundaEmail author
  • Manuel Pérez-Miranda
  • Uwe Will
  • Sebastian Ullrich
  • Dirk Brenke
  • Markus Dollhopf
  • Michelle Meier
  • Alberto Larghi



A novel lumen-apposing, self-expanding metal stent to perform EUS-guided drainage procedures has been recently developed. The aim of this study was to analyze the safety, technical and clinical effectiveness of this device for EUS-guided choledochoduodenostomy (EUS-CD) with palliative intent.


Retrospective analysis of all consecutive patients with unresectable malignant distal bile duct obstruction who, between March 2012 and September 2014, underwent EUS-CD using the study devices (AXIOS™ and Hot AXIOS™, Xlumena Inc., Mountain View, CA, USA) after unsuccessful ERCP in seven European centers was carried out.


Fifty-seven patients (M/F 31/26; median age 73) underwent EUS-CD using the AXIOS™ stent or the Hot AXIOS™ delivery system. ERCP failure was due to duodenal obstruction in 41 patients (71.9 %) and to inability to cannulate the papilla in the remaining 16 patients (28.1 %). The procedure was technically successful in 56/57 patients (98.2 %), with a mean procedural time of 22.4 min (range 11–65). Clinical success was achieved in 54 of these 56 patients (96.4 %; 94.7 % of the entire cohort). Overall major procedural complication rate was 7 % (two duodenal perforations, one bleeding and one transient cholangitis). During follow-up, 5 out of 54 (9.3 %) patients with clinica success required re-intervention for stent migration in one case and a sump syndrome with transient increase in serum bilirubin concentrations with sludge in the distal duct reservoir in the remaining four patients.


Our study shows that EUS-CD using the AXIOS™ and the Hot AXIOS™ devices is a safe procedure, with high technical and clinical success rates.


EUS-guided biliary drainage Failed ERCP choledochoduodenostomy SEMSs Interventional EUS 



Dr. Rastislav Kunda is a consultant/speaker for Boston Scientific Corp. and for Olympus Medical. Dr. Manuel Pérez-Miranda is a consultant/speaker for Boston Scientific Corp., Xlumena and Gore. Dr. Alberto Larghi is a consultant/speaker for Cook Medical, Boston Scientific Corp., Covidien and Xlumena. Dr. Uwe Will, Dr. Sebastian Ullrich, Dr. Markus Dollhopf and Dr. Michelle Meier have no conflicts of interest or financial ties to disclose.


  1. 1.
    Halttunen J, Meisner S, Aabakken L, Arnelo U, Grönroos J, Hauge T, Kleveland PM, Nordblad Schmidt P, Saarela A, Swahn F, Toth E, Mustonen H, Löhr JM (2014) Difficult cannulation as defined by a prospective study of Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs. Scand J Gastroenterol 49:752–758CrossRefPubMedGoogle Scholar
  2. 2.
    Bailey AA, Bourke MJ, Williams SJ, Walsh PR, Murray MA, Lee EY, Kwan V, Lynch PM (2008) A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis. Endoscopy 40:296–301CrossRefPubMedGoogle Scholar
  3. 3.
    Ho CS, Warkentin AE (2012) Evidence-based decompression in malignant biliary obstruction. Korean J Radiol 13(Suppl 1):S56–S61CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Glazer ES, Hornbrook MC, Krouse RS (2014) A meta-analysis of randomized trials: immediate stent placement vs. surgical bypass in the palliative management of malignant biliary obstruction. J Pain Symptom Manage 47:307–314CrossRefPubMedGoogle Scholar
  5. 5.
    Rogart JN (2012) Endoscopic biliary access: endoscopic ultrasound joins the party. J Clin Gastroenterol 46:723–724CrossRefPubMedGoogle Scholar
  6. 6.
    Khashab MA, Dewitt J (2013) EUS-guided biliary drainage: is it ready for prime time? Yes! Gastrointest Endosc 7:102–105CrossRefGoogle Scholar
  7. 7.
    Kahaleh M, Artifon EL, Perez-Miranda M, Gupta K, Itoi T, Binmoeller KF, Giovannini M (2013) Endoscopic ultrasonography guided biliary drainage: summary of consortium meeting, May 7th, 2011, Chicago. World J Gastroenterol 19:1372–1379CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Gupta K, Perez-Miranda M, Kahaleh M, Artifon EL, Itoi T, Freeman ML, de Serna C, Sauer B, Giovannini M, In EBD STUDY GROUP (2014) Endoscopic ultrasound-assisted bile duct access and drainage: multicenter, long-term analysis of approach, outcomes, and complications of a technique in evolution. J Clin Gastroenterol 48:80–87CrossRefPubMedGoogle Scholar
  9. 9.
    Fabbri C, Luigiano C, Lisotti A, Cennamo V, Virgilio C, Caletti G, Fusaroli P (2014) Endoscopic ultrasound-guided treatments: are we getting evidence based. A systematic review. World J Gastroenterol 20:8424–8448CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Fuccio L, Attili F, Vanella G, Larghi A (2014) Interventional endoscopic ultrasonography. Curr Treat Options Gastroenterol 12:183–210CrossRefPubMedGoogle Scholar
  11. 11.
    Itoi T, Binmoeller KF, Shah J, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Moriyasu F (2012) Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 75:870–876CrossRefPubMedGoogle Scholar
  12. 12.
    Teoh AY, Binmoeller KF, Lau JY (2014) Single-step EUS-guided puncture and delivery of a lumen-apposing stent for gallbladder drainage using a novel cautery-tipped stent delivery system. Gastrointest Endosc 80:1171CrossRefPubMedGoogle Scholar
  13. 13.
    Walter D, Will U, Sanchez-Yague A, Brenke D, Hampe J, Wollny H, López-Jamar JM, Jechart G, Vilmann P, Gornals JB, Ullrich S, Fähndrich M, de Tejada AH, Junquera F, Gonzalez-Huix F, Siersema PD, Vleggaar FP (2015) A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study. Endoscopy 47:63–67CrossRefPubMedGoogle Scholar
  14. 14.
    Galasso D, Baron TH, Attili F, Zachariah K, Costamagna G, Larghi A (2015) Endoscopic ultrasound-guided drainage and necrosectomy of walled-off pancreatic necrosis using a metal stent with an electrocautery-enhanced delivery system. Endoscopy 47(Suppl 1):E68PubMedGoogle Scholar
  15. 15.
    Shah RJ, Shah JN, Waxman I, Kowalski TE, Sanchez-Yague A, Nieto J, Brauer BC, Gaidhane M, Kahaleh M (2015) Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered self-expanding metal stents. Clin Gastroenterol Hepatol 13:747–752CrossRefPubMedGoogle Scholar
  16. 16.
    Rinninella E, Kunda R, Dollhopf M, Sanchez-Yague A, Will U, Tarantino I, Gornals Soler J, Ullrich S, Meining A, Esteban JM, Enz T, Vanbiervliet G, Vleggaar F, Attili F, Larghi A (2015) EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery enhanced delivery system: a large retrospective study. Gastrointest Endosc 82:1039–1046CrossRefPubMedGoogle Scholar
  17. 17.
    Walter D, Teoh AY, Itoi T, Pérez-Miranda M, Larghi A, Sanchez-Yague A, Siersema PD, Vleggaar FP (2016) EUS-guided gallbladder drainage with a lumen-apposing metal stent: a prospective long-term evaluation. Gut 65:6–8CrossRefPubMedGoogle Scholar
  18. 18.
    Tarantino I, Barresi L, Granata A, Ligresti D, Curcio G, Traina M (2015) Single-step EUS-guided choledocoduodenostomy and stenting. Gastrointest Endosc 81:1016–1017CrossRefPubMedGoogle Scholar
  19. 19.
    Rimbas M, Attili F, Larghi A (2015) Single-session EUS-guided FNA and biliary drainage with use of a biflanged lumen-apposing stent on an electrocautery enhanced delivery system: 1-stop shop for unresectable pancreatic mass with duodenal obstruction. Gastrointest Endosc 2:405CrossRefGoogle Scholar
  20. 20.
    Artifon EL, Aparicio D, Paione JB, Lo SK, Bordini A, Rabello C, Otoch JP, Gupta K (2012) Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage. J Clin Gastroenterol 46:768–774CrossRefPubMedGoogle Scholar
  21. 21.
    Khashab MA, Valeshabad AK, Afghani E, Singh VK, Kumbhari V, Messallam A, Saxena P, El Zein M, Lennon AM, Canto MI, Kalloo AN (2015) A comparative evaluation of EUS-guided biliary drainage and percutaneous drainage in patients with distal malignant biliary obstruction and failed ERCP. Dig Dis Sci 60:557–565CrossRefPubMedGoogle Scholar
  22. 22.
    Dhir V, Artifon EL, Gupta K, Vila JJ, Maselli R, Frazao M, Maydeo A (2014) Multicenter study on endoscopic ultrasound-guided expandable biliary metal stent placement: choice of access route, direction of stent insertion, and drainage route. Dig Endosc 26:430–435CrossRefPubMedGoogle Scholar
  23. 23.
    Park do H, Jeong SU, Lee BU, Lee SS, Seo DW, Lee SK, Kim MH (2013) Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video). Gastrointest Endosc 78:91–101CrossRefPubMedGoogle Scholar
  24. 24.
    Nguyen-Tang T, Binmoeller KF, Sanchez-Yague A, Shah JN (2010) Endoscopic ultrasound (EUS)-guided transhepatic anterograde self-expandable metal stent (SEMS) placement across malignant biliary obstruction. Endoscopy 42:232–236CrossRefPubMedGoogle Scholar
  25. 25.
    Artifon EL, Safatle-Ribeiro AV, Ferreira FC, Poli-de-Figueiredo L, Rasslan S, Carnevale F, Otoch JP, Sakai P, Kahaleh M (2011) EUS-guided antegrade transhepatic placement of a self-expandable metal stent in hepatico-jejunal anastomosis. JOP 12:610–613PubMedGoogle Scholar
  26. 26.
    Wang K, Zhu J, Xing L, Wang Y, Jin Z, Li Z (2015) Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review. Gastrointest Endosc. doi: 10.1016/j.gie.2015.10.033 [Epub ahead of print] PubMedCentralGoogle Scholar
  27. 27.
    Khashab MA, Valeshabad AK, Modayil R, Widmer J, Saxena P, Idrees M, Iqbal S, Kalloo AN, Stavropoulos SN (2013) EUS-guided biliary drainage by using a standardized approach for malignant biliary obstruction: rendezvous versus direct transluminal techniques (with videos). Gastrointest Endosc 78:734–741CrossRefPubMedGoogle Scholar
  28. 28.
    Wang AY, Ellen K, Berg CL, Schmitt TM, Kahaleh M (2009) Fully covered self-expandable metallic stents in the management of complex biliary leaks: preliminary data—a case series. Endoscopy 41:781–786CrossRefPubMedGoogle Scholar
  29. 29.
    Artifon EL, Marson FP, Gaidhane M, Kahaleh M, Otoch JP (2015) Hepaticogastrostomy or choledochoduodenostomy for distal malignant biliary obstruction after failed ERCP: is there any difference? Gastrointest Endosc 81:950–959CrossRefPubMedGoogle Scholar
  30. 30.
    Leppard WM, Shary TM, Adams DB, Morgan KA (2011) Choledochoduodenostomy: is it really so bad? J Gastrointest Surg 15:754–757CrossRefPubMedGoogle Scholar
  31. 31.
    Demirel BT, Kekilli M, Onal IK, Parlak E, Disibeyaz S, Kacar S, Kilic ZM, Sasmaz N, Sahin B (2011) ERCP experience in patients with choledochoduodenostomy: diagnostic findings and therapeutic management. Surg Endosc 25:1043–1047CrossRefPubMedGoogle Scholar
  32. 32.
    Baker AR, Neoptolemos JP, Leese T, Fossard DP (1987) Choledochoduodenostomy, transduodenal sphincteroplasty and sphincterotomy for calculi of the common bile duct. Surg Gynecol Obstet 164:245–251PubMedGoogle Scholar
  33. 33.
    Baker AR, Neoptolemos JP, Carr-Locke DL, Fossard DP (1985) Sump syndrome following choledochoduodenostomy and its endoscopic treatment. Br J Surg 72:433–435CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Rastislav Kunda
    • 1
    Email author
  • Manuel Pérez-Miranda
    • 2
  • Uwe Will
    • 3
  • Sebastian Ullrich
    • 4
  • Dirk Brenke
    • 5
  • Markus Dollhopf
    • 6
  • Michelle Meier
    • 1
  • Alberto Larghi
    • 7
  1. 1.Department of Surgical Gastroenterology LAarhus University HospitalAarhus CDenmark
  2. 2.Department of Gastroenterology and HepatologyHospital Universitario Rio HortegaValladolidSpain
  3. 3.Department of GastroenterologyMunicipal HospitalGeraGermany
  4. 4.Department of Internal Medicine IAsklepios Klinik AltonaHamburgGermany
  5. 5.Department of GastroenterologyStädtisches KlinikumKarlsruheGermany
  6. 6.Department of GastroenterologyKlinikum NeuperlachMunichGermany
  7. 7.Digestive Endoscopy UnitCatholic UniversityRomeItaly

Personalised recommendations