Can endoscopic ultrasound‐guided gallbladder drainage be an alternative biliary drainage in all cases after failed endoscopic retrograde cholangiopancreatography?

In this issue of Digestive Endoscopy, Debourdeau et al.1 reported comparable outcomes of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CDS) and EUS-guided gallbladder drainage (EUS-GBD) for distal malignant biliary obstruction (dMBO) after failed endoscopic retrograde cholangiopancreatography. In their multicenter, retrospective study, the clinical success rate was 87.8% for EUS-GBD and 89.2% for EUS-CDS, and the periprocedure (<24 h) adverse event rate was 9.8% for EUS-GBD and 13.5% for EUS-CDS. Notably, late (>24 h) adverse events were less observed in EUS-GBD (7.5% for EUS-GBD and 21.6% for EUS-CDS), which was mainly attributable to less stent obstruction in EUS-GBD. EUS-GBD as a rescue drainage for dMBO has been increasingly reported,2-4 but we have to be aware of the patient selection to interpret the clinical outcomes. First, as previously discussed in surgical cholecystojejunostomy, patency of the cystic duct needs to be evaluated prior to EUS-GBD.5 Second, the size of the common bile duct was significantly larger in EUS-CDS in the current study (13.47 mm in EUS-GBD and 18.19 mm in EUS-CDS),1 which is due to the space necessary for lumen-apposing metal stent (LAMS) deployment. Finally, the appropriate LAMS size or the drainage route of LAMS for EUS-GBD needs to be clarified. While large LAMS can be selected in EUS-GBD, it may increase the risk of food impaction. The LAMS size in EUS-CDS was 6 mm in 97.3%, but the size of LAMS in EUS-GBD was 10 or 15 mm in 87.8%, and a transgastric approach was applied to stay away from the tumor invasion.1 In contrast, Mangiavillano et al.4 recommended a smaller LAMS for the transgastric approach to prevent food impaction. Thus, the appropriate approach route and the LAMS size might differ by the anatomy, such as the duodenal stricture as well as the gallbladder location. Furthermore, duodenal invasion, which is often concomitant with dMBO (>40% in this study), was reported as the only risk factor for stent dysfunction of EUS-CDS using LAMS.6 Congestion in the duodenum would increase food impaction or cholangitis due to duodenobiliary reflux through LAMS in the duodenum, and a transgastric approach may prolong stent patency, and EUS-guided hepaticogastrostomy (EUS-HGS), in addition to transgastric EUS-GBD, might be preferred to EUS-CDS in cases with severe duodenal invasion.7, 8 In summary, EUS-GBD is considered a valid treatment drainage option for MBO, with potentially less stent occlusion. However, it cannot be a routine first-line treatment option, as the procedure is appropriate only for cases with patent cystic duct above MBO. Future studies should focus on treatment selection among EUS-GBD, CDS, and HGS based on the location of MBO, the presence of duodenal stricture, or the availability of LAMS. Author Y.N. received research grants and honoraria from Boston Scientific Japan. Y.N. serves as an Associate Editor of Digestive Endoscopy. None.