Download PDF
Endoscopy
DOI: 10.1055/a-2541-2973
Original article

Technical failure of endoscopic ultrasound-guided choledochoduodenostomy: multicenter study on rescue techniques, consequences, and risk factors

Clara Beunon
1   Department of Digestive Endoscopy, Université Paris Cité, Beaujon University Hospital (APHP), Clichy, France
2   Department of Pancreatology and Digestive Oncology, Université Paris Cité, Beaujon University Hospital (APHP), CRMR PaRaDis Pancreatic Rare Diseases, Clichy, France
,
Antoine Debourdeau 
3   Gastroenterology Unit, CHU de Nîmes, CHU de Montpellier, Montpellier University MUSE, Montpellier, France
,
Marion Schaefer
4   Hepato-Gastroenterology Department, Nancy Regional University Hospital Center, Nancy, France
,
Timothée Wallenhorst
5   Gastroenterology Unit, CHU Rennes, Rennes, France
,
Enrique Perez-Cuadrado-Robles
6   Department of Gastroenterology, Université Paris Cité, Hopital Européen Georges Pompidou (APHP), Paris, France
,
Arthur Belle
7   Department of Gastroenterology, Université Paris Cité, Cochin University Hospital (APHP), Paris, France
,
Jean-Michel Gonzalez 
 8   Department of Gastroenterology, Université Aix Marseille, Hôpital Nord (APHM), Marseille, France
,
Marine Camus Duboc 
 9   Department of Endoscopy, Université Sorbonne, Saint Antoine University Hospital (APHP), Paris, France
,
Fabrice Caillol 
10   Department of Gastroenterology, Institut Paoli Calmettes, Marseille, France
,
Hervé-Pierre Toudic
11   Gastroenterology Department, Brest University Hospital, Brest, France
,
Mathieu Pioche
12   Gastroenterology Unit, Hôpital Edouard Herriot, Lyon, France
,
Jean Baptiste Danset
13   Gastroenterology Unit, Hôpital Saint-Joseph, Paris, France
,
Adrien Sportes
14   Gastroenterology Unit, Institut Arnault Tzanck, Saint Laurent du Var, France
,
Bertrand Brieau
15   Gastroenterology Unit, Clinique Jules Vernes, Nantes, France
,
Emmanuel Ben Soussan
16   Gastroenterology Unit, Clinique de l’Alma, Paris, France
,
Mathilde Petiet
17   Gastroenterology Unit, Grand Hôpital de l’Est Francilien, Meaux, France
,
Antoine Martin
18   Gastroenterology Unit, CHU Hôpital Bicêtre (APHP), Kremlin-Bicêtre, France
,
Sarra Oumrani
19   Gastroenterology Unit, CHUV, Lausanne, Switzerland
,
Frédérique Maire
2   Department of Pancreatology and Digestive Oncology, Université Paris Cité, Beaujon University Hospital (APHP), CRMR PaRaDis Pancreatic Rare Diseases, Clichy, France
,
Arnaud Lemmers
20   Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, HUB (Hôpital Universitaire de Bruxelles), ULB (Université Libre de Bruxelles), Brussels, Belgium
,
Frédéric Prat
1   Department of Digestive Endoscopy, Université Paris Cité, Beaujon University Hospital (APHP), Clichy, France
,
Ludovic Caillo
21   Gastroenterology Unit, CHU de Nîmes, Montpellier Univ, MUSE, France
,
Romain Gérard
22   Gastroenterology and Endoscopy Unit, CHU Lille, Lille, France
,
Jérémie Albouys
23   Gastroenterology and Endoscopy Unit, CHU Limoges, Limoges, France
,
Diane Lorenzo
1   Department of Digestive Endoscopy, Université Paris Cité, Beaujon University Hospital (APHP), Clichy, France
,
and the ETC Working Group
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints


Abstract

Background We aimed to determine risk factors for technical failure of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS), evaluate short- and long-term consequences, and identify salvage techniques in patients with biliary obstruction.

Methods This retrospective multicenter study of EUS-CDS (2018–2024) included technical failure, classified as type 1 (digestive flange mispositioned), type 2 (biliary flange mispositioned), type 3 (stent deployment failure), type 4 (catheter/lumen-apposing metal stent [LAMS] through the bile duct), and type 5 (others). Controls were successful EUS-CDS in the same center and period. The primary end point was risk factors for failure. Secondary end points were endoscopic rescue techniques and immediate- and long-term consequences.

Results Technical failure occurred in 7 % (95 %CI 5–9). Across 23 centers, 296 patients were analyzed (mean age 71 [SD 16] years, 53 % male), including 100 technical failures: type 1 (26 %), type 2 (41 %), type 3 (11 %), type 4 (6 %), type 5 (16 %). Risk factors for technical failure in multivariate analysis included CBD diameter ≤ 15 mm, duodenal stenosis, wired technique, and low operator experience (≤ 10 LAMS). Endoscopic salvage was successful in 77 %, with 53 % using a covered metal stent and 22 % using a new LAMS. Early failures were mild in 56 % of cases, but 12 % resulted in death within 30 days. Immediate endoscopic salvage reduced severe clinical adverse events (P < 0.001) and increased success rates (P < 0.001).

Conclusions EUS-CDS failures were not rare and were severe in half of cases. Recognizing risk factors, identifying failures during the procedure, and knowing endoscopic salvage methods are crucial.

Supplementary Material



Publication History

Received: 11 June 2024

Accepted after revision: 17 February 2025

Accepted Manuscript online:
17 February 2025

Article published online:
14 May 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Neuzillet C, Gaujoux S, Williet N. et al. Pancreatic cancer: French clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC). Dig Liver Dis 2018; 50: 1257-1271
    PubMedSearch in Google Scholar
  • 2 Pavlidis ET, Pavlidis TE. Pathophysiological consequences of obstructive jaundice and perioperative management. Hepatobiliary Pancreat Dis Int 2018; 17: 17-21
    CrossrefPubMedSearch in Google Scholar
  • 3 Dumonceau J-M, Tringali A, Papanikolaou I. et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline – updated October 2017. Endoscopy 2018; 50: 910-930
    Thieme ConnectPubMedSearch in Google Scholar
  • 4 Bang JY, Navaneethan U, Hasan M. et al. Stent placement by EUS or ERCP for primary biliary decompression in pancreatic cancer: a randomized trial (with videos). Gastrointest Endosc 2018; 88: 9-17
    CrossrefPubMedSearch in Google Scholar
  • 5 Teoh AYB, Napoleon B, Kunda R. et al. EUS-guided choledocho-duodenostomy using lumen apposing stent versus ERCP with covered metallic stents in patients with unresectable malignant distal biliary obstruction: a multicenter randomized controlled trial (DRA-MBO trial). Gastroenterology 2023; 165: 473-482.e2
    CrossrefPubMedSearch in Google Scholar
  • 6 van der Merwe SW, van Wanrooij RLJ, Bronswijk M. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 185-205
    Thieme ConnectPubMedSearch in Google Scholar
  • 7 Amato A, Sinagra E, Celsa C. et al. Efficacy of lumen-apposing metal stents or self-expandable metal stents for endoscopic ultrasound-guided choledochoduodenostomy: a systematic review and meta-analysis. Endoscopy 2021; 53: 1037-1047
    Thieme ConnectPubMedSearch in Google Scholar
  • 8 Holt BA, Hawes R, Hasan M. et al. Biliary drainage: role of EUS guidance. Gastrointest Endosc 2016; 83: 160-165
    CrossrefPubMedSearch in Google Scholar
  • 9 Debourdeau A, Daniel J, Caillo L. et al. Effectiveness of endoscopic ultrasound (EUS)‐guided choledochoduodenostomy vs. EUS‐guided gallbladder drainage for jaundice in patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography: retrospective, multicenter study (GALLBLADEUS Study). Dig Endosc 2025; 37: 103-114
    PubMedSearch in Google Scholar
  • 10 Giovannini M, Moutardier V, Pesenti C. et al. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy 2001; 33: 898-900
    Thieme ConnectPubMedSearch in Google Scholar
  • 11 Isayama H, Nakai Y, Kawakubo K. et al. Recent progress in endoscopic ultrasonography guided biliary intervention. Clin J Gastroenterol 2012; 5: 93-100
    PubMedSearch in Google Scholar
  • 12 Itoi T, Binmoeller KF. EUS-guided choledochoduodenostomy by using a biflanged lumen-apposing metal stent. Gastrointest Endosc 2014; 79: 715
    PubMedSearch in Google Scholar
  • 13 Walter D, Will U, Sanchez-Yague A. et al. A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study. Endoscopy 2015; 47: 63-67
    PubMedSearch in Google Scholar
  • 14 Geyl S, Redelsperger B, Yzet C. et al. Risk factors for stent dysfunction during long-term follow-up after EUS-guided biliary drainage using lumen-apposing metal stents: a prospective study. Endosc Ultrasound 2023; 12: 237-244
    CrossrefPubMedSearch in Google Scholar
  • 15 Vanella G, Bronswijk M, Dell’Anna G. et al. Classification, risk factors, and management of lumen apposing metal stent dysfunction during follow-up of endoscopic ultrasound-guided choledochoduodenostomy: multicenter evaluation from the Leuven–Amsterdam–Milan Study Group. Dig Endosc 2023; 35: 377-388
    CrossrefPubMedSearch in Google Scholar
  • 16 Jacques J, Privat J, Pinard F. et al. Endoscopic ultrasound-guided choledochoduodenostomy with electrocautery-enhanced lumen-apposing stents: a retrospective analysis. Endoscopy 2019; 51: 540-547
    Thieme ConnectPubMedSearch in Google Scholar
  • 17 Ginestet C, Sanglier F, Hummel V. et al. EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent placement should replace PTBD after ERCP failure in patients with distal tumoral biliary obstruction: a large real-life study. Surg Endosc 2022; 36: 3365-3373
    CrossrefPubMedSearch in Google Scholar
  • 18 Krishnamoorthi R, Dasari CS, Thoguluva Chandrasekar V. et al. Effectiveness and safety of EUS-guided choledochoduodenostomy using lumen-apposing metal stents (LAMS): a systematic review and meta-analysis. Surg Endosc 2020; 34: 2866-2877
    CrossrefPubMedSearch in Google Scholar
  • 19 Albouys J, Guilmoteau T, Schaefer M. et al. How to prevent and treat biliary lumen-apposing metal stent dysfunction?. Dig Endosc 2024; 36: 492-494
    PubMedSearch in Google Scholar
  • 20 Artifon ELA, Aparicio D, Paione JB. et al. Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage. J Clin Gastroenterol 2012; 46: 768
    CrossrefPubMedSearch in Google Scholar
  • 21 Han SY, Kim S-O, So H. et al. EUS-guided biliary drainage versus ERCP for first-line palliation of malignant distal biliary obstruction: a systematic review and meta-analysis. Sci Rep 2019; 9: 1-9
    CrossrefPubMedSearch in Google Scholar
  • 22 Chen Y-I, Sahai A, Donatelli G. et al. Endoscopic ultrasound-guided biliary drainage of first intent with a lumen-apposing metal stent vs endoscopic retrograde cholangiopancreatography in malignant distal biliary obstruction: a multicenter randomized controlled study (ELEMENT trial). Gastroenterology 2023; 165: 1249-1261.e5
    CrossrefPubMedSearch in Google Scholar
  • 23 Van Wanrooij RLJ, Bronswijk M, Kunda R. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2022; 54: 310-332
    Thieme ConnectPubMedSearch in Google Scholar
  • 24 Dietrich CF, Braden B, Burmeister S. et al. How to perform EUS-guided biliary drainage. Endosc Ultrasound 2022; 11: 342-354
    CrossrefPubMedSearch in Google Scholar
  • 25 Biau DJ, Williams SM, Schlup MM. et al. Quantitative and individualized assessment of the learning curve using LC-CUSUM. Br J Surg 2008; 95: 925-929
    PubMedSearch in Google Scholar
  • 26 Armellini E, Metelli F, Anderloni A. et al. Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: a systematic review focusing on issues and rescue management. World J Gastroenterol 2023; 29: 3341-3361
    CrossrefPubMedSearch in Google Scholar
  • 27 Khoury T, Sbeit W, Fumex F. et al. Endoscopic ultrasound vs. ERCP-guided primary drainage of inoperable distal malignant biliary obstruction: systematic review and meta-analysis of randomized controlled trials. Endoscopy 2024; 56: 955-963
    Thieme ConnectPubMedSearch in Google Scholar
  • 28 Vanella G, Dell’Anna G, Capurso G. et al. EUS-guided gastroenterostomy for management of malignant gastric outlet obstruction: a prospective cohort study with matched comparison with enteral stenting. Gastrointest Endosc 2023; 98: 337-347.e5
    CrossrefPubMedSearch in Google Scholar
  • 29 Ghandour B, Bejjani M, Irani SS. et al. Classification, outcomes, and management of misdeployed stents during EUS-guided gastroenterostomy. Gastrointest Endosc 2022; 95: 80-89
    CrossrefPubMedSearch in Google Scholar
  • 30 Nass KJ, Zwager LW, van der Vlugt M. et al. Novel classification for adverse events in GI endoscopy: the AGREE classification. Gastrointest Endosc 2022; 95: 1078-1085.e8
    CrossrefPubMedSearch in Google Scholar
  • 31 Fritzsche JA, Fockens P, Besselink MG. et al. Endoscopic ultrasound-guided choledochoduodenostomy using single-step lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-p): a prospective pilot study. Endoscopy 2024; 56: 47-52
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Çavuşoğlu SD, Doğanay M, Birben B. et al. Management of bile duct injuries: a 6-year experience in a high volume referral center. Euroasian J Hepatogastroenterol 2020; 10: 22-26
    PubMedSearch in Google Scholar
  • 33 Elmassry M, Haché B, Thongpiya J. et al. Endoscopic ultrasound–guided choledochoduodenostomy with lumen-apposing metal stent through duodenal stent, a success case, and a salvage case. ACG Case Rep J 2024; 11: e01315
    PubMedSearch in Google Scholar