Background
Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with lumen-apposing metal stents (LAMS) may be used in patients with a distal malignant biliary obstruction in whom either conventional biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) failed or as primary drainage approach in research setting. Although EUS-CDS has shown promising results, experience with EUS-CDS prior to pancreatoduodenectomy (PD) is still limited. Therefore, in daily clinical practice multidisciplinary teams are reluctant to opt for EUS-CDS in patients with potentially resectable tumors.

Methods
Patients who underwent a PD between January 2020 and December 2022 after preoperative biliary drainage by EUS-CDS were included. Prospectively collected data from patients in the Dutch Pancreatic Cancer Audit were retrospectively analyzed. Primary endpoint was major postoperative complications, defined as Clavien-Dindo score ≥3. Secondary endpoints included overall complications, pancreatic surgery specific complications (i.e. postoperative pancreatic fistula, delayed gastric emptying, hemorrhage, and chyle leakage), in-hospital mortality and hospital stay. A propensity score matching (1:4) analysis was performed using patient and tumor characteristics, neoadjuvant therapy, type of stent, and hospital volume. Surgeons who performed a PD in a patient who underwent pre-operative EUS-CDS were requested to fill-out a 5-questions survey directly after the surgical procedure.

Results
Overall, 641 patients after PD were included of whom 34 (5.3%) underwent EUS-CDS. Major postoperative complications occurred in 174 patients (28.7%) in the ERCP group and 6 patients (17.6%) in the EUS-CDS group (RR 0.55; 95% CI, 0.23-1.30). No significant differences were observed between the groups in the secondary endpoints. Time between biliary drainage and surgery in patients without neoadjuvant therapy differed significantly between the ERCP group (median 39 days; IQR, 28-52) and EUS-CDS group (32 days; IQR, 21.5-39.5; p=0.021). Operative time was shorter in the EUS-CDS group (mean 329 min [SD 88] vs 299 min [SD 68]; p=0.004). Results were similar after propensity-score matching.

The survey was completed in 25 PD’s after EUS-CDS. In the majority (n=19, 76%) there was no direct visualization of the stent during the PD. In most patients, the resection was not (n=13, 52%) or slightly (n=7, 28%) considered complicated by the LAMS according to the surgeon. The stent did not hamper the creation of the hepaticojejunostomy.

Conclusion
This nationwide retrospective study found EUS-CDS to be safe without increase in (major) postoperative complications after PD as compared to ERCP. Moreover, surgeons did not encounter evident difficulties during most of the resections.

Erwin-Jan van Geenen

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