One-step EUS-CDS versus ERCP in first-line drainage for malignant distal biliary obstruction

Background: Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is a potential first-line drainage method for unresectable malignant distal biliary obstruction (UMDBO); however, its effectiveness remains uncertain. This study evaluated the utility of one-step EUS-CDS with a tubular dumbbell-shaped metal stent (MS).
Methods: In total, 224 patients with UMDBO met the inclusion criteria. Technical and clinical success, procedure time, and adverse events (AEs) including recurrent biliary obstruction (RBO) were compared between the EUS-CDS group and ERCP group who underwent transpapillary uncovered MS placement. Propensity score matching was performed to adjust for between-group differences.
Results: Technical success rates in the EUS-CDS and ERCP groups were 97.2% and 90.1%, respectively (P=0.166). Clinical success was achieved in all technically successful cases in both groups. The median procedure time was significantly shorter in the EUS-CDS group than in the ERCP group (12 min vs. 23 min, P<0.001), whereas the rates of early and late AE besides RBO were not significantly different between the groups. The EUS-CDS group demonstrated a significantly lower RBO incidence rate (13.0% vs. 37.5%, respectively; P=0.001) and significantly longer median time to RBO (NA vs. 186 days, P=0.008) compared to the ERCP group. Multivariate analysis revealed that EUS-CDS was associated with a significantly longer time to RBO.
Conclusions: One-step EUS-CDS using tubular MS with an appropriate anti-migration function may be a useful option for primary drainage in patients with UMDBO.