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

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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.

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Authors and Affiliations

  1. Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA, 70121, USA

    Abdul H. El Chafic, Janak N. Shah, Ricardo V. Romero & John A. Evans

  2. California Pacific Medical Center, San Francisco, CA, USA

    Chris Hamerski & Kenneth F. Binmoeller

  3. Virginia Mason Medical Center, Seattle, WA, USA

    Shayan Irani

  4. University of North Carolina, Chapel Hill, NC, USA

    Theodore W. James & Todd H. Baron

  5. Borland-Groover Clinic, Jacksonville, FL, USA

    Jose Nieto

  6. Weill Cornell Medicine, New York, NY, USA

    Michel Kahaleh

Authors
  1. Abdul H. El Chafic
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Corresponding author

Correspondence to Abdul H. El Chafic.

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Conflict of interest

AE, TB, KB, JN, SI, and JS have served as consultants for Boston Scientific. KB is the inventor of AXIOS stent and delivery system. MK has received research funding from Boston Scientific.

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An institutional review board approval was obtained at each participating site for this retrospective study.

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El Chafic, A.H., Shah, J.N., Hamerski, C. et al. EUS-Guided Choledochoduodenostomy for Distal Malignant Biliary Obstruction Using Electrocautery-Enhanced Lumen-Apposing Metal Stents: First US, Multicenter Experience. Dig Dis Sci 64, 3321–3327 (2019). https://doi.org/10.1007/s10620-019-05688-2

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  • DOI: https://doi.org/10.1007/s10620-019-05688-2

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