Introduction
Biliary drainage (BD) in patients with distal malignant biliary obstruction (DMBO) implies a higher risk of difficult biliary cannulation (DBC) during endoscopic retrograde cholangiopancreatography (ERCP). When standard techniques, (sphincterotome, and guidewire) fail, the endoscopist may proceed with advanced cannulation techniques, such as the double
guidewire technique, needle-knife precut papillotomy or fistulotomy, and transpancreatic sphincterotomy. Despite the higher risk of adverse events, these advanced strategies can still fail in
up to 15% of cases. In recent times, endoscopic ultrasound-guided biliary drainage (EUS-BD) emerged as a viable alternative in case of DBC due to its favorable profile in terms of both technical success, and safety.
Aims & Methods
Multi-center (4 centers), international (Italy, France), retrospective, propensity score-matched study including patients with DMBO, and common bile duct (CBD) diameter >12mm. DBC cases managed with either advanced cannulation techniques (aERCP group), or direct EUS- guided approach (performed straight away after failure of standard cannulation; EUS-BD group) were considered for the analysis. A 2:1 propensity score-matched analysis was performed balancing age, sex, and CBD diameter to reduce confounding, and ensure comparability between groups. The outcomes of interest were the rates BD failure, clinical success, and adverse events (AEs).
Results
Standard cannulation techniques failed in 524 cases during the study period. Advanced cannulation techniques, and EUS-guided approach were attempted in 472, and 52 cases, respectively. After matching, 76 (aERCP group), and 38 patients (EUS-BD group) were included in the analysis (age: 77.4+10.5 and 76.7+12.6, male: 70.6% vs 71.1%, CBD diameter: 16.5+2.9 and 17.2+3.3, respectively). In aERCP group, also advanced cannulation techniques failed in 17 22.4%) cases, however all these patients were successfully treated by EUS-guided approach as a rescue strategy. No cases of BD failure were reported in EUS-BD group (p<0.05). Clinical success was comparable between the two groups (aERCP:91.2%, vs EUS-BD:94.7%, p=0.46). The 20.6% of patients experienced AEs in the aERCP group (7 cholangitis, 6 pancreatitis, 2 bleeding, 2 other), compared to the 7.9% reported in EUS-BD group (2 cholangitis, 1 pancreatitis, 1 bleeding; p=0.14).
Conclusion
EUS-guided biliary drainage shows higher technical success rate compared to advanced cannulation techniques, with comparable clinical success. Regarding safety, the observed trend of reduced adverse events (AEs) with the EUS-guided approach may require a larger, adequately powered study to confirm statistical significance. In patients with dilated CBD (>12mm).
EUS-BD may be considered an efficient option in case of DBC, possibly minimizing the risk of adverse events.
