Risk factors for obstruction of choledochoduodenostomy by lumen-apposing metal stent and management strategies: Results from a prospective cohort of 168 patients

Aims In case of distal malignant biliary obstructions, when ERCP (endoscopic retrograde cholangiopancreatography) fails, drainage via EUS-CDS (endoscopic ultrasound-guided choledochoduodenostomy) using LAMS (lumen-apposing metal stent) has become the gold standard. The data regarding stent obstruction during follow-up are heterogeneous and range from 9 to 55%¹. Identified risk factors include the presence of a duodenal stent², duodenal invasion³, and a bile duct diameter<15mm². The objective of our study is to identify risk factors for stent obstruction, evaluate the efficacy of obstruction management, and define the best strategy for managing these stent obstructions.

Methods We conducted a retrospective study of a monocentric prospective database, including all patients treated with EUS-CDS for distal biliary obstruction between 2017 and 2024 in a French university hospital. Obstruction was defined as persistent and/or recurrent jaundice and/or acute cholangitis during follow-up.

Results A total of 168 patients were included in our study. The overall stent correct function rate was 72%, with a mean follow-up of 176 days (5.8 months) [1] [2] [3]. We confirmed that gastrointestinal obstruction was a risk factor for stent obstruction in both univariate analysis (OR=4.22 [1.91; 9.31], p=0.001) and multivariate analysis (OR=4.67 [2.05; 10.65], p=0.0002). Regarding the best management strategy for stent obstruction, placing a new pig-tail or metallic stent within the lumen-apposing stent is more effective than simple mechanical desobstruction or antibiotic therapy alone. There was a a higher rate of biliary event-free survival during follow-up (at 6 months 92.3% versus 58.9%; at 12 months 80.8% versus 47.1%).

Conclusions We confirm that gastrointestinal obstruction is a risk factor for stent obstruction in EUS-CDS procedures. In cases of cholangitis or persistent jaundice, endoscopic desobstruction by placing a new pig-tail or metallic stent is more effective than simple desobstruction or antibiotic therapy.

Conflicts of Interest

Boston Scientific

• References

• 1 Geyl S. 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.”. Endoscopic ultrasound 2023; 12 (02): 237-244
• 2 Vanella 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.”. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2023; 35 (03): 377-388
• 3 Fritzsche JA. 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 (01): 47-52

Publication History

Article published online:
27 March 2025