Outcomes and Complications of Combined EUS- guided and ERCP Stenting in Biliary Drainage

Aims Biliary drainage can be challenging in patients with recurrent or advanced biliary obstructions, often requiring dual interventions. Combining EUS-guided biliary drainage (EUS- BD) with endoscopic retrograde cholangiopancreatography (ERCP) guided stenting may enhance drainage efficacy; however, little data exists on the outcomes and complication rates associated with this dual-stenting approach. This study examines the clinical outcomes and safety profile of combining EUS-guided biliary drainage and ERCP in patients with challenging biliary strictures, focusing on efficacy, stent patency, complication rates, and re-intervention requirements.

Methods A retrospective analysis was conducted on patients who underwent combined EUS- BD and ERCP stenting for biliary obstruction from March 2020 to September 2024 at our tertiary referral center. The patients had undergone combined stenting in one session, or the EUS-guided biliary drainage was performed after one or more ERCP- sessions. The studied data included patient demographics, primary diagnosis, procedural details, and outcomes, specifically stent patency duration, efficacy in symptom relief, and complications such as stent-related infections and pancreatitis.

Results Of the 29 patients who received combined stenting, 86,2% experienced adequate drainage and symptom relief post-procedure. In all patients, the biliary stenosis was malignant; 15 patients (51.7%) had Bismuth type III/IV stenosis, six patients (20.6%) had Bismuth type I/II stenosis, and eight patients (27.5%) had distal stenosis. In 8 patients (27,6%), the combined stenting was done in one session, while in 21 (72.4%), the EUS-guided drainage was implemented after at least one previous ERCP without adequate drainage. The mean number of previous ERCP procedures was 2.95. The median stent patency for combined stenting is 4 months. However, dual stenting was associated with a relatively high incidence of complications, with 24.1% experiencing stent-related infections and 10,3% presenting with pancreatitis. Re-intervention was required in 6,8% of dual-stented patients, primarily due to stent obstruction and acute cholangitis.

Conclusions While combined EUS-guided biliary drainage and ERCP stenting offers enhanced biliary drainage for complex cases and lowers the re-intervention rate, it is associated with relatively high complication rates. Careful patient selection and vigilant post-procedural monitoring are advised to lessen risks. The combined approach may be considered in patients potentially requiring many ERCP sessions or cases of complex hilar strictures where single transpapillary intervention is expected to be less effective. Further studies are needed to refine dual-intervention strategies and identify candidates who may benefit most from this approach.

Publication History

Article published online:
27 March 2025