Inoue Tadahisa, Kitano Rena, Kitada Tomoya, Futagami Shun, Yano Masato, Sakamoto Kazumasa, Kimoto Satoshi, Arai Jun, Ito Kiyoaki
Department of Gastroenterology, Aichi Medical University, Nagakute, Aichi, Japan.
Department of Gastroenterology, Aichi Medical University, Nagakute, Aichi, Japan.
Gastrointest Endosc. 2025 May 29. doi: 10.1016/j.gie.2025.05.024.
EUS-guided choledochoduodenostomy (CDS) is a potential first-line drainage method for unresectable malignant distal biliary obstruction (UMDBO). However, lumen-apposing metal stents present difficulty in application for insufficient bile duct dilation, biliary wall compression, duodenobiliary reflux, and high cost. This study evaluated the utility of fistula dilation-free EUS-CDS with a tubular dumbbell-shaped metal stent (MS).
In total, 224 patients with UMDBO met the inclusion criteria. Technical and clinical success, procedure time, and adverse events (AEs) including recurrent biliary obstruction (RBO) were compared between the EUS-CDS group and ERCP group who underwent transpapillary uncovered MS placement.
After one-to-one propensity score matching, 71 patients were included in each group. Technical success rates in the EUS and ERCP groups were 97.2% and 90.1%, respectively (P = .166). Clinical success was achieved in all technically successful cases in both groups. The median procedure time was significantly shorter in the EUS group than in the ERCP group (12 minutes vs 23 minutes, P < .001), whereas the rates of early and late AEs besides RBO were not significantly different between the groups. The EUS group demonstrated a significantly lower RBO incidence rate (13.0% vs 37.5%, respectively; P = .001) and significantly longer median time to RBO (not applicable vs 186 days, P = .008) compared with the ERCP group. Multivariate analysis revealed that EUS-CDS was associated with a significantly longer time to RBO.
Fistula dilation-free EUS-CDS using tubular MS with an appropriate antimigration function may be a useful option for primary drainage in patients with UMDBO.
内镜超声引导下胆总管十二指肠吻合术（CDS）是不可切除的恶性远端胆管梗阻（UMDBO）潜在的一线引流方法。然而，管腔贴附金属支架在应用中存在困难，原因包括胆管扩张不足、胆管壁受压、十二指肠胆管反流以及成本高昂。本研究评估了使用管状哑铃形金属支架（MS）的无瘘管扩张内镜超声引导下CDS的效用。
共有224例UMDBO患者符合纳入标准。比较了内镜超声引导下CDS组和接受经乳头无覆膜MS置入的内镜逆行胰胆管造影（ERCP）组的技术成功率、临床成功率、手术时间以及包括复发性胆管梗阻（RBO）在内的不良事件（AE）。
经过一对一倾向评分匹配后，每组纳入71例患者。内镜超声组和ERCP组的技术成功率分别为97.2%和90.1%（P = 0.166）。两组所有技术成功的病例均取得了临床成功。内镜超声组的中位手术时间显著短于ERCP组（12分钟对23分钟，P < 0.001），而除RBO外的早期和晚期AE发生率在两组之间无显著差异。与ERCP组相比，内镜超声组的RBO发生率显著更低（分别为13.0%对37.5%；P = 0.001），且RBO的中位时间显著更长（不可用对186天，P = 0.008）。多变量分析显示内镜超声引导下CDS与RBO发生时间显著更长相关。
使用具有适当抗移位功能的管状MS进行无瘘管扩张内镜超声引导下CDS可能是UMDBO患者初次引流的一种有用选择。
