Management of ERCP Failure in Malignant Biliary Obstruction: Comparative Effectiveness and Safety of EUS-Guided Gallbladder Drainage Versus Choledocoduodenostomy.

Benedetto Mangiavillano, Gianluca Franchellucci, Francesco Auriemma, Daryl Ramai, Alessandro Fugazza, Marco Spadaccini, Carmelo Barbera, Giuseppe Vanella, Germana De Nucci, Andrew Fuller, Belén Martínez-Moreno, Roberto Di Mitri, Francesco Di Matteo, Carlos Robles Medranda, Andrea Anderloni, Luca De Luca, Anthony Yuen Bun Teoh, Jorge Vargas-Madrigal, Edoardo Forti, Michiel Bronswijk, Santi Mangiafico, Helga Bertani, Sundeep Lakhtakia, Khanh Do-Cong Pham, Stefano Francesco Crinò, Sridhar Sundaram, Alessandro Repici, Antonio Facciorusso

Journal: Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2026;38(4):e70145

PMID: 41948877

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Abstract

OBJECTIVES

It is unclear which is the best approach for the drainage of malignant distal biliary obstruction (MDBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). We compared endoscopic ultrasound (EUS)-guided gallbladder drainage (GBD) and EUS-guided choledocoduodenostomy (CDS) with lumen-apposing metal stents (LAMS) as rescue treatment in the case of ERCP failure.

METHODS

This was an international multicenter retrospective observational study at 28 tertiary-care centers. Outcomes were compared using propensity score matching (PSM). Clinical success was the primary outcome, with technical success, adverse event (AE) rate, and overall survival being the secondary outcomes.

RESULTS

Five hundred twenty-nine patients underwent EUS-guided drainage, of which 136 underwent EUS-GBD, and 393 underwent EUS-CDS. After 1-to-1 PSM, 112 patients per group were selected. EUS-GBD and EUS-CDS had similar technical success (97.3% and 91%; p = 0.08) and clinical success rates (83% and 85.7%; p = 0.17). AE rate was 19.6% in the EUS-GBD group and 12.5% in the EUS-CDS group (p = 0.20), of which 10 (8.9%) and 7 (6.2%) were severe AEs respectively (p = 0.61). Bleeding occurred in seven patients (6.1%) after EUS-GBD and three patients (2.5%) after EUS-CDS, whereas five infectious events were registered after EUS-GBD (4.4%) and four cases (3.5%) after EUS-CDS (p = 0.29). No treatment-related deaths were observed.

CONCLUSION

In patients with MDBO after failed ERCP, EUS-GBD or EUS-CDS were comparable with similar rates of efficacy and safety. EUS-GBD could represent an easy and safe option in MDBO patients without previous cholecystectomy and with a clear patency of the cystic duct.

Address: Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy.; Department of Biomedical Sciences, Humanitas University, Milan, Italy.; Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Rozzano, Italy.; Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Rozzano, Italy.; IBD Unit, Department of Gastroenterology, Humanitas University, Milan, Italy.; Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy.; Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.; Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Rozzano, Italy.; Department of Biomedical Sciences, Humanitas University, Milan, Italy.; Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Rozzano, Italy.; Gastroenterology and Endoscopy Unit, Ospedale G. Mazzini, Teramo, Italy.; Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Institute and Vita-Salute University, Milan, Italy.; Gastroenterology and Endoscopy Unit, Aziende Socio Sanitaria Territoriale Rhodense, Garbagnate Milanese, Milan, Italy.; Division of Gastroenterology, Hepatology, and Nutrition, University of Utah, Salt Lake City, Utah, USA.; Endoscopy Unit, Department of Digestive Diseases, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.; Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Palermo, Italy.; Therapeutic GI Endoscopy Unit, Campus Bio-Medico University Hospital, Roma, Italy.; Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador.; Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.; Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy.; Unit of Gastroenterology and Digestive Endoscopy, ASST Santi Paolo e Carlo, Milan, Italy.; Department of Surgery, HK Sanatorium & Hospital, Hong Kong City, Hong Kong.; Gastroenterology Department, Enrique Baltodano Briceno Hospital, Liberia, Costa Rica.; Digestive Endoscopy, Ospedale Niguarda-Ca' Granda, Milan, Italy.; Gastroenterology and Hepatology, KU Leuven University Hospitals Leuven, Leuven, Belgium.; Gastroenterology Unit Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", Catania, Italy.; Gastroenterologia ed Endoscopia Digestiva Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy.; Medical Gastroenterology, AIG Hospitals, Hyderabad, India.; Department of Medicine, Haukeland University Hospital, Bergen, Norway.; Diagnostic and Interventional Endoscopy of Pancreas, University Hospital of Verona, Verona, Italy.; Department of Digestive Disease and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India.; Department of Experimental Medicine, Section of Gastroenterology, University of Salento, Lecce, Italy.

DOI: 10.1111/den.70145

MeSH Terms: Humans, Male, Female, Retrospective Studies, Drainage, Cholangiopancreatography, Endoscopic Retrograde, Aged, Endosonography, Cholestasis, Middle Aged, Treatment Failure, Ultrasonography, Interventional, Choledochostomy, Treatment Outcome, Stents, Bile Duct Neoplasms