Stent Dysfunction in EUS-choledochoduodenostomy for Malignant Biliary Obstruction

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Aims EUS-choledochoduodenostomy (EUS-CDS) is established as a second-line treatment modality for the management of malignant biliary obstruction. Despite documented rates of clinical success upwards of 97%, data pertaining to stent dysfunction are limited. Methods A retrospective observational study was conducted at a tertiary referral centre in Toronto, Canada. All patients who underwent attempted EUS-CDS with a lumen-apposing metal stent (LAMS) between June 2019 and June 2024 were included. Primary outcomes were technical and clinical success, respectively defined as successful LAMS placement, and normalization or>50% reduction in bilirubin. Secondary outcomes included risk factors for stent dysfunction. Results 50 patients underwent EUS-CDS (mean age 73.7±10.8 years; 34 (68%) female). Median CBD diameter on EUS was 17 mm (IQR 15-20 mm), with 10 (20%) being≤14 mm. The main cause of obstruction was pancreatic adenocarcinoma in 36 (72%). Overall technical and clinical success rates were 98% and 96% respectively. LAMS diameter was 6 mm in 38 (76%) and 8 mm in 12 (24%). A plastic pigtail stent was placed through the LAMS in 31 (62%). In cases with a CBD≤14 mm, technical and clinical success rates were 100% and 90%. At a median follow up of 5.2 months (IQR 2.4-10.6), stent dysfunction occurred in 10 (20%), at a median of 1.8 months (IQR 0.8-4.6). None occurred after 6 months. Of these, 1 was palliated and 9 underwent re-intervention, which included a sweep of the LAMS (n=9), re(placement) of plastic stents (n=9), and insertion of a duodenal stent (n=6 with new duodenal obstruction). Stent patency at 12-months was 71.9% ( Figure 1 ). Adverse events included intra-procedural bleeding in 1 (2%). There were no cases of peritonitis, delayed bleed or delayed perforation. While LAMS diameter and duodenal obstruction were associated with stent dysfunction on univariate analysis (Table 1), only duodenal obstruction was significant on multivariate analysis (HR 7.8, 95%CI 1.8-33.9, P=0.006). There was no association with the type of cancer, CBD size or placement of a plastic stent. Conclusions In an expert tertiary centre, excellent rates of technical and clinical success can be achieved, including in CBD diameters≤14 mm. Stent patency at 12-months was 71.9%, with occlusion usually occurring early at a median of 1.8 months. This was associated with duodenal obstruction, which could be readily managed with duodenal stent placement. Future studies should assess the utility of prophylactic or early intervention in those at risk of duodenal obstruction at time of EUS-CDS. Publication History Article published online: 27 March 2025 © 2025. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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