Post written by Roy van Wanrooij, MD, PhD, from the Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.

EUS-guided choledochoduodenostomy (EUS-CDS) is increasingly used in management of malignant distal biliary obstruction, not only as a rescue strategy after failed ERCP, but also as the primary drainage strategy. Its growing adaptation is driven by high technical and clinical success rates along with negligible risk of postprocedural pancreatitis.

However, a key limitation remains its relatively high rate of stent dysfunction, possibly hindering broader implementation. Although the introduction of the all-in-one lumen-apposing metal stent (LAMS) has facilitated easier and safer stent placement, dysfunction is mainly attributed to the stent’s design.

We conducted a prospective single-center pilot study evaluating EUS-CDS as the primary drainage strategy in patients with malignant distal biliary obstruction, using a LAMS with coaxial placement of a fully covered self-expandable metal stent (FCSEMS). This approach aimed to preserve the benefits of the LAMS while leveraging the FCSEMS to overcome its shortcomings, effectively offering a “best of both worlds” solution. The intrabiliary segment of the FCSEMS prevents obstruction of the perpendicularly placed LAMS by the contralateral bile duct wall, while the intraduodenal segment of the FCSEMS aligns with the duodenal lumen, forming a barrier that prevents influx of food.

None of the 18 patients in whom the LAMS and FCSEMS were adequately placed experienced stent dysfunction, underlining the potential benefit of this new stent design. However, this strategy proved technically challenging, as FCSEMS placement through the LAMS failed in 4 patients and, in 1 case, the FCSEMS was positioned too short in the bile duct, necessitating reintervention.

This proof-of-concept study demonstrates that modifying the LAMS design can effectively reduce the stent dysfunction rate. Yet, the approach used in this study remains technically challenging and financially unsustainable. These findings highlight the need for dedicated stent design modifications specifically tailored to optimize outcomes in EUS-CDS.

Placement of a fully covered self-expandable metal stent (FCSEMS) through the lumen-apposing metal stent (LAMS). EUS-guided choledochoduodenostomy using a electrocautery-enhanced LAMS with a coaxial FCSEMS placed through the LAMS. A, Sonographic identification of the common bile duct (CBD) proximal to the tumor. A target site where the CBD was ≥12 mm, with no intervening vessels or ascites, was identified. B, Endoscopic image of bile flow out of the LAMS, showing the disadvantageous position of the stent pointing in the direction of the pylorus. C, Endoscopic image after FCSEMS placement through the LAMS, showing the improved outflow of the stent in the direction of the second part of the duodenum. D, CT image of the position of the FCSEMS through the LAMS. E, A guidewire was advanced through the LAMS to facilitate placement of a FCSEMS, showing the perpendicular axis of the LAMS with the bile duct. F, Fluoroscopic image of the FCSEMS through the LAMS, showing the nonperpendicular stent axis in the bile duct.

Read the full 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.