Technical failure of endoscopic ultrasound-guided choledochoduodenostomy: multicenter study on rescue techniques, consequences, and risk factors
Clara Beunon, Antoine Debourdeau, Marion Schaefer, Timothée Wallenhorst, Enrique Pérez‐Cuadrado‐Robles, Arthur Belle, Jean‐Michel Gonzalez, Marine Camus, Fabrice Caillol, Hervé-Pierre Toudic, Mathieu Pioche, J B Danset, Adrien Sportes, Bertrand Brieau, E Ben Soussan, Mathilde Petiet, Antoine Martin, Sarra Oumrani, Frédérique Maire, Arnaud Lemmers, Frédéric Prat, Ludovic Caillo, Romain Gérard, Jérémie Albouys, Diane Lorenzo, and the ETC Working Group
Abstract
Background We aimed to determine risk factors for technical failure of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS), evaluate short- and long-term consequences, and identify salvage techniques in patients with biliary obstruction. Methods This retrospective multicenter study of EUS-CDS (2018–2024) included technical failure, classified as type 1 (digestive flange mispositioned), type 2 (biliary flange mispositioned), type 3 (stent deployment failure), type 4 (catheter/lumen-apposing metal stent [LAMS] through the bile duct), and type 5 (others). Controls were successful EUS-CDS in the same center and period. The primary end point was risk factors for failure. Secondary end points were endoscopic rescue techniques and immediate- and long-term consequences. Results Technical failure occurred in 7 % (95 %CI 5–9). Across 23 centers, 296 patients were analyzed (mean age 71 [SD 16] years, 53 % male), including 100 technical failures: type 1 (26 %), type 2 (41 %), type 3 (11 %), type 4 (6 %), type 5 (16 %). Risk factors for technical failure in multivariate analysis included CBD diameter ≤ 15 mm, duodenal stenosis, wired technique, and low operator experience (≤ 10 LAMS). Endoscopic salvage was successful in 77 %, with 53 % using a covered metal stent and 22 % using a new LAMS. Early failures were mild in 56 % of cases, but 12 % resulted in death within 30 days. Immediate endoscopic salvage reduced severe clinical adverse events (P < 0.001) and increased success rates (P < 0.001). Conclusions EUS-CDS failures were not rare and were severe in half of cases. Recognizing risk factors, identifying failures during the procedure, and knowing endoscopic salvage methods are crucial.