Bile duct drainage by endoscopic cholecystoduodenostomy as a bridge to pancreaticoduodenectomy for malignant obstructive jaundice

Abstract

A series of 6 cases was analyzed in which endoscopic ultrasound-guided cholecystoduodenostomy (EUS-CD) was performed because biliary stent placement by ERCP was not possible for the treatment of malignant obstructive jaundice prior to pancreaticoduodenectomy (PD). The Hot-Axios® device was used in combination with a coaxial pigtail. No complications were reported related to the procedure or associated with PD. EUS-CD has been shown to be a safe and effective procedure for preoperative improvement of jaundice in these patients. The fact that it can be performed simultaneously with the failed ERCP, without delaying surgery, and the absence of complications or worsening prognosis makes it an effective and safe alternative to percutaneous transhepatic biliary drainage (PTBD).

Resumen

Se ha analizado una serie de 6 casos en los que se ha realizado una colecistoduodenostomía ecoendoscópica (CDE) al no ser posible la colocación de una prótesis biliar por CPRE para el tratamiento de la ictericia obstructiva de origen maligno previo a una duodenopancreatectomía (DP). El dispositivo utilizado fue el Hot-Axios® asociado a un pigtail coaxial. No se han producido complicaciones relacionadas con el procedimiento ni asociadas a la DP. La CDE se ha mostrado como un procedimiento seguro y eficaz que permite en estos pacientes la mejoría preoperatoria de la ictericia. El hecho de que pueda realizarse en el mismo acto que la CPRE fallida, sin demorar la cirugía, asociado a la ausencia de complicaciones ni empeoramiento pronóstico, la convierte en una alternativa efectiva y segura al drenaje biliar transhepático percutáneo (CPTH).

Introduction

The usefulness of the bile duct drainage technique by means of endoscopic ultrasound-guided cholecystoduodenostomy (EUS-CD) is well known in cases where biliary stent placement is not possible by ERCP.¹ This procedure was described as an alternative to cholecystectomy in inoperable patients, but it has since gained popularity in the treatment of malignant obstructive jaundice in patients receiving palliative care.² Recently, EUS-CD cholecystoduodenostomy has been described as a bridging therapy for malignant obstructive jaundice prior to definitive surgical treatment, such as pancreaticoduodenectomy.³

Results of the surgical technique

For this study, we analyzed all cases of PD performed by the Pancreatic Surgery Unit of our hospital in which a Hot Axios® device had been previously placed under EUS as a preoperative method for bile duct drainage (Fig. 1a). The clinical-pathological history and results of the biliary drainage procedure and subsequent surgery were analyzed for all cases, and the data are summarized in Table 1.

Fig. 1.

a) EUS image from procedure; b) CT for re-staging after neoadjuvant therapy, where the EUS-CD device is observed; c) intraoperative image of the cholecystoduodenal communication; d) Hot-Axios® device with pigtail.

Table 1.

Clinical-pathological history andresults.

	Case	ASA	Reason for EUS-CD	Procedure	Etiology	dBR 1	dBR 2	dBR 3	TTS	COMP	CD
1	M 68	3	Cannulation	CG 10 × 10 mm	CC T3N2	8.9	2.9	0.6	90 days	No	0
2	F 83	3	Cannulation	CD 10 × 15 mm	ADC T2N2	6.3	2	0.6	37 days	No	2
3	M 70	3	Cannulation	CD 10 × 10 mm	ADC T3N1	7.6	3.2	2.1	45 days	No	2
4	F 74	3	Failed RV	CD 10 × 10 mm	ADC T2N0	6.2	1.6	1.6	45 days	No	2
5	F 71	3	Gallbladder C-T	CD 10 × 10 mm	ADC T2N2	4.4	1.2	1.3	40 days	No	2
6	F 82	3	Cannulation	CD 15 × 10 mm	ADC T4N2	16.6	8.3	0.3	150 days	No	2

F, female; M, male; RV, Rendez-Vous; C-T, Courvoisier-Terrier; CG, cholecystogastrostomy; CD, cholecystoduodenostomy; CC, cholangiocarcinoma; ADC, adenocarcinoma of the pancreas; dBR 1, pre-procedure direct bilirubin; dBR 2, post-procedure direct bilirubin (72 h); dBR 3, preoperative direct bilirubin; TTS, time to surgery; COMP, complications of the surgery; CD, Clavien-Dindo.

In the last 2 years (2023–2024), 6 PD were performed, in which the preoperative biliary drainage method was EUS-guided cholecystoenteric bypass. The main reason for performing this procedure was the inability to perform biliary cannulation during ERCP, so EUS-CD was performed in its place. The procedure was successfully performed in all cases where it was attempted. The most frequently used device was the 10 × 10 mm Hot-Axios®, with a coaxial pigtail (Fig. 1b) to prevent stent collapse. No complications occurred related to the procedure or associated with PD. The resolution of obstructive jaundice was effective, dropping from a direct bilirubin (dBR) of 8.3 (4.4–16.6) mg/dL to 3.2 (1.2–8.3) mg/dL in the first 72 h after the procedure. This was maintained in all cases, with a mean preoperative dBR of 1.08 (0.3–2.1), including one borderline resectable case treated previously with neoadjuvant therapy in which surgery was delayed 150 days. In all cases, the device was cultured postoperatively, and targeted antibiotic treatment was initiated.

Discussion

It is well known that jaundice can have negative effects on coagulation and the immune system; therefore, most guidelines recommend preoperative biliary drainage.^4,5 The most commonly used procedure for this purpose is the placement of a coated plastic or metal stent using ERCP.⁶ However, this technique is not exempt from placement failures and serious complications, such as acute pancreatitis.^7–10

The results of this study support the use of preoperative biliary drainage using EUS-CD as an alternative to ERCP in patients undergoing PD. The feasibility of this strategy was demonstrated in all patients in whom it was attempted and effective biliary drainage was achieved, as evidenced by the rapid and sustained decrease in bilirubin levels. The absence of complications during endoscopic anastomosis does not compromise or delay the surgical procedure, unlike post-ERCP pancreatitis or the need to perform a new procedure, such as percutaneous transhepatic biliary drainage (PTBD).

Another important finding of this study is that EUS-CD does not alter or complicate the PD surgical technique. In fact, it even makes en bloc resection of the surgical specimen possible, without the need for intraoperative stent removal (Fig. 1c and 1d). This reduces the risk of surgical field contamination without increasing the risk of hypothetical peritoneal tumor dissemination. Thus, its main advantage is the preservation of the surgical field and resection margins, which are crucial aspects in oncological treatment. In this regard, it is superior to choledochoduodenostomy because, although the reduction in jaundice may be slower, its short-term effectiveness is comparable. Furthermore, our results indicate that EUS-CD does not increase postoperative complications after pancreaticoduodenectomy, further demonstrating its safety and tolerability.

However, the need for specialized experience in HBP procedures and referral centers restricts its applicability to a select group of endoscopists. Furthermore, although cholelithiasis and cholecystitis are not impediments but rather potential indications, the technique has significant contraindications, such as previous biliary surgery or Roux-en-Y biliary-pancreatic bypass, which also limit ERCP. In addition, the higher cost of cholecystoduodenostomy (due to the higher price of the Hot-Axios® device compared to classic biliary stents) poses an additional challenge for its widespread implementation. Nonetheless, being able to perform the procedure in a single operation reduces the hospital stay versus having to schedule PTBD, which could ultimately even out the costs.

To our knowledge, this article presents the first series of patients treated with EUS-CD as a bridge to PD in cases of malignant obstructive jaundice. However, despite the favorable results and less tumor manipulation, which suggest its potential use as an alternative to ERCP with stent placement, further experience and more scientific evidence are needed before it can be considered the procedure of choice. This study is a single-center case series performed in selected patients at a tertiary care center, which does not provide high-level evidence to indicate the widespread use of this procedure. Hence, multicenter comparative studies are needed to support these results.

In conclusion, EUS-CD is a safe, effective procedure for preoperative improvement of jaundice in selected patients with malignant biliary obstruction in whom biliary drainage by ERCP is not possible. The fact that it can be performed at the same time as a failed ERCP (without delaying surgery) and the absence of complications or worsened prognosis make it a safe, effective alternative to PTBD.

Funding

No external funding was received.