ERCP or EUS-BD for malignant distal CBD obstruction

Dr. DhirVinay Dhir, MD from the Department of Endoscopy and Endosonography, Baldota Institute of Digestive Sciences in Mumbai, India discusses his Original Article “Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach.”

ERCP is the procedure of choice for relief of jaundice due to malignant distal obstruction. However, ERCP may fail in these patients due to duodenal stenosis or papillary involvement. EUS-guided biliary drainage has shown success rates in excess of 90% in recent series. Currently EUS-BD is done for patients with failed ERCP,thus increasing the number of procedures, hospital stay and costs. We hypothesized that results of EUS-BD are comparable to ERCP for distal malignant biliary obstruction.

There is no study comparing results of ERCP and EUS-BD. Due to earlier published studies, there is an impression that EUS-BD carries higher morbidity. However recent studies have not shown this. If the results of ERCP and EUS-BD are comparable, then we have another alternative endoscopic procedure for biliary decompression.

Figure 2

Figure 2.Technique of EUS-antegrade procedure. A, B, EUS image showing dilated left intrahepatic biliary radical and needle puncture of the biliary radical. C, D, Cholangiogram showing dilated biliary radicals and wire manipulated across the hilum into distal common bile duct (CBD). E, F, 6F cystotome manipulated into distal CBD. Cystotome manipulated across the papilla with contrast injection showing duodenal folds. G, H, expandable stent inserted; good drainage of contrast


Our study showed that, at expert centers, results of ERCP and EUS-BD for malignant distal bile duct obstruction are comparable. We also showed that in patients with TypeII duodenal stenosis, results of EUS-BD were superior to ERCP. Additionally, when results of  patients with difficult cannulation during ERCP were compared to EUS-BD, the success rates were significantly higher and pancreatitis rates significantly lower for the EUS-BD group. Thus EUS-BD appears to perform better than ERCP in patients with difficult cannulation, and those with duodenal stenosis. This was a retrospective comparison, and a prospective randomized comparison will be needed to confirm this finding.

This study was conducted at centers with high skills at ERCP and EUS-BD. These results may not apply to community practice.

Find the abstract for this article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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