Download PDF
Endoscopy
DOI: 10.1055/a-2625-3307
Editorial

Endoscopic ultrasound-guided choledochoduodenostomy using lumen-apposing metal stents: a call for standardized training, rescue management, and revision of stent design

Referring to Beunon C et al. doi: 10.1055/a-2541-2973
Rogier P. Voermans 
1   Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, Netherlands
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has emerged as a promising alternative to endoscopic retrograde cholangiopancreatography (ERCP). The introduction of lumen-apposing metal stents (LAMS) simplified EUS-CDS and facilitated widespread adoption. It is now considered the preferred approach for distal malignant obstruction in cases of failed ERCP. Moreover, in some expert centers it has even replaced ERCP as the primary drainage modality in selected cases. By bypassing both the tumor and the papilla, EUS-CDS simplifies biliary access and may be associated with a favorable safety profile because of the absence of post-procedural pancreatitis. Indeed, two recent RCTs demonstrated elimination of post-ERCP pancreatitis, although the overall adverse event rate remained comparable between EUS-CDS and ERCP [1] [2].

“…this large cohort study clearly shows that to ensure the safe and effective use of EUS-CDS, a combination of structured training, adequate patient selection, and standardized rescue strategies, is essential…”

However, concerns persist regarding recurrent biliary obstruction [3] [4] and technical failures [5], which may be associated with significant consequences for patients. In this issue of Endoscopy, Beunon et al. present a retrospective case–control study focusing on technical failure [6]. Data were extracted from a large European database (n = 618, details not provided). The study matched 100 cases with technical failure with 196 successful EUS-CDS procedures performed within the same center and time period. The authors should be applauded for this critical evaluation of outcomes of EUS-CDS failures in a large group of patients. This study underscores that EUS-CDS with LAMS is not without significant risks. With a reported 7% technical failure rate and striking 12% 30-day mortality rate in failed cases (with majority of fatalities directly attributable to the failure), a reassessment of how this procedure is introduced and performed is necessary. What can we learn from these data?



Publication History

Article published online:
18 June 2025

© 2025. Thieme. All rights reserved.

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

 

  • References

  • 1 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
    CrossrefPubMedSearch in Google Scholar
  • 2 Chen YI, 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
    CrossrefPubMedSearch in Google Scholar
  • 3 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
  • 4 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
  • 5 Chen YI, Long C, Sahai AV. et al. Stent misdeployment and factors associated with failure in endoscopic ultrasound-guided choledochoduodenostomy: analysis of the combined datasets from two randomized trials. Endoscopy 2025; 57: 330-338
    PubMedSearch in Google Scholar
  • 6 Beunon C, Debourdeau A, Schaefer M. et al. Technical failure of endoscopic ultrasound-guided choledocoduodenostomy: multicenter study on rescue techniques, consequences, and risk factors. Endoscopy 2025; 57
    Thieme ConnectPubMedSearch in Google Scholar