Biliary drainage prior to pancreatoduodenectomy with EUS-guided choledochoduodenostomy versus conventional ERCP

The study compared two methods of preoperative biliary drainage for patients undergoing pancreatoduodenectomy: endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and conventional endoscopic retrograde cholangiopancreatography (ERCP). Preoperative biliary drainage is often necessary but can lead to complications that complicate surgery. EUS-CDS has been proposed as a safer alternative to ERCP, but its impact on surgical outcomes and complexity was unclear.

The study analyzed 937 patients across eight Dutch centers, with 42 undergoing EUS-CDS and 895 undergoing ERCP before surgery. Major postoperative complications occurred in 19% of EUS-CDS patients compared to 33% of ERCP patients, suggesting a trend toward fewer major complications with EUS-CDS (relative risk 0.50), although this difference was not statistically significant. Secondary outcomes, such as overall complications, bile leaks, and pancreatic fistulas, were similar between the two groups. Propensity score-matched analysis confirmed these findings, indicating no significant difference in postoperative risk between the techniques.

Surgeons reported that prior EUS-CDS rarely made surgery more challenging, with most finding it not (45%) or only slightly (31%) more difficult. Only 24% found it clearly or severely more complex.

Overall, EUS-CDS appears to be a safe and effective preoperative biliary drainage method, with no significant impact on postoperative complications or surgical complexity.