Role of endoscopic-ultrasound-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction

Abstract

In this editorial, we discuss the article by Peng et al in the recent issue of the World Journal of Gastrointestinal Surgery, focusing on the evolving role of endoscopic-ultrasound-guided biliary drainage (EUS-BD) with electrocautery lumen apposing metal stent (LAMS) for distal malignant biliary obstruction. Therapeutic endoscopy has rapidly advanced in decompression techniques, with growing evidence of its safety and efficacy surpassing percutaneous and surgical approaches. While endoscopic retrograde cholangiopancreatography (ERCP) has been the gold standard for biliary decompression, its failure rate approaches 10.0%, prompting the exploration of alternatives like EUS-BD. This random-effects meta-analysis demonstrated high technical and clinical success of over 90.0% and an adverse event rate of 17.5%, mainly in the form of stent dysfunction. Outcomes based on stent size were not reported but the majority used 6 mm and 8 mm stents. As the body of literature continues to demonstrate the effectiveness of this technique, the challenges of stent dysfunction need to be addressed in future studies. One strategy that has shown promise is placement of double-pigtail stents, only 18% received the prophylactic intervention in this study. We expect this to improve with time as the technique continues to be refined and standardized. The results above establish EUS-BD with LAMS as a reliable alternative after failed ERCP and considering EUS to ERCP upfront in the same session is an effective strategy. Given the promising results, studies must explore the role of EUS-BD as first-line therapy for biliary decompression.

Keywords: Endoscopic-ultrasound; Malignant biliary obstruction; Lumen apposing metal stent; Choledochoduodenostomy; Hepaticogastrostomy

Core Tip: Endoscopic-ultrasound (EUS)-guided biliary drainage with lumen apposing metal stent proves to be a viable and secure alternative following failed endoscopic retrograde cholangiopancreatography (ERCP) for distal malignant biliary obstruction. Given these promising results, adding EUS to ERCP upfront for distal obstruction is a reasonable strategy. Despite its efficacy, stent dysfunction remains a notable constraint. When performing this procedure, careful consideration must be given to the stent size, patient anatomy, availability of accessories, and therapeutic objectives. Patients should have regular follow-ups to ensure the patency of these stents.