Biliary drainage in pancreatic cancer with duodenal invasion: which route is the best?

Tanyaporn Chantarojanasiri; Thawee Ratanachu-Ek

doi:10.5946/ce.2024.301

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Editorial Biliary drainage in pancreatic cancer with duodenal invasion: which route is the best?: Tanyaporn Chantarojanasiri^1,, Thawee Ratanachu-Ek²; Clinical Endoscopy 2025;58(1):82-84.
DOI: https://doi.org/10.5946/ce.2024.301
Published online: January 24, 2025

¹Department of Internal Medicine, Rajavithi Hospital, College of Medicine Rangsit University, Bangkok, Thailand

²Rajavithi Digestive Endoscopy Center, Rajavithi Hospital, College of Medicine Rangsit University, Bangkok, Thailand

Correspondence: Tanyaporn Chantarojanasiri Department of Internal Medicine, Rajavithi Hospital, College of Medicine Rangsit University, 2 Phayathai Road, Ratchathewi District, Bangkok 10400, Thailand Email: chtunya@gmail.com

• Received: November 14, 2024 • Revised: November 22, 2024 • Accepted: November 24, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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REFERENCES

See the article "Endoscopic ultrasound-guided hepaticogastrostomy and endoscopic retrograde cholangiopancreatography-guided biliary drainage for distal malignant biliary obstruction due to pancreatic cancer with asymptomatic duodenal invasion: a retrospective, single-center study in Japan" on page 134.

We read with great interest the publication by Takahara et al.,¹ who compared the stent patency between endoscopic retrograde cholangiopancreatography (ERCP) with metallic stenting and endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for malignant biliary obstruction from pancreatic cancer with asymptomatic duodenal invasion. The study demonstrated trends toward longer stent patency in patients receiving EUS-HGS than in patients receiving ERCP, with a median time to biliary obstruction of 8.8 and 5.7 months, respectively. However, notably, these differences did not reach statistical significance. The authors defined recurrent biliary obstruction as either stent occlusion or stent migration, with tissue hyperplasia being the primary cause of stent occlusion in the EUS-HGS group, and sludge or food impaction contributing to stent occlusion in the ERCP group. Notably, post-ERCP pancreatitis was observed in 6.5% of cases, whereas none were observed in the EUS-HGS group.

Pancreatic cancer is notorious for its late presentation and the concomitant development of biliary and duodenal obstructions. In advanced disease, palliative biliary drainage is crucial for symptom relief and enables the administration of chemotherapy. Traditionally, transpapillary stenting is the most commonly performed biliary drainage route. However, this approach is not always successful because passage of the duodenoscope to approach the ampulla can be challenging or even unfeasible in cases of duodenal invasion. In this context, other routes of biliary drainage have been used, with endoscopic ultrasound-guided biliary drainage (EUS-BD) now replacing percutaneous biliary drainage.² In cases of malignant distal biliary strictures, either endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) or EUS-HGS are feasible. In a recent meta-analysis comparing these two procedures, both methods provided similar efficacy and adverse events, with EUS-CDS being associated with a shorter procedure time.³ However, in cases with duodenal obstruction, EUS-CDS might be more technically demanding, and shorter stent patency was observed, compared with EUS-HGS, despite the use of an indwelling duodenal stent.⁴ Moreover, a higher rate of non-occluded cholangitis was observed after EUS-CDS, and conversion from EUS-CDS to EUS-HGS was observed in up to 46% of the patients.

Several studies have directly compared ERCP and EUS-BD for malignant distal biliary obstruction. In 2024, three systematic reviews and meta-analyses of randomized controlled trials were published across three high-impact journals.⁵^-⁷ All three noted the lower reintervention rate with EUS-BD than with ERCP, with comparable efficacy⁷ and shorter hospital stay.⁵ These data suggest that EUS-BD is a promising alternative to biliary drainage. However, the success rates and complication profiles observed in these high-volume centers may not be directly transferable to healthcare settings with lower experience or fewer cases.

Several factors influence the biliary stent patency. In plastic stents, occlusion occurs due to bacterial biofilm and sludges.⁸ Tumor ingrowth and tissue hyperplasia are the leading causes of stent occlusion.⁹ Moreover, duodenobiliary reflux, which is observed in all cases after the placement of a metallic stent across the papilla,¹⁰ has been implicated in stent failure, as the reflux of duodenal contents into the biliary tree may contribute to obstruction. This raises concerns, particularly in patients with duodenal invasion, as the presence of indwelling biliary drainage in an obstructed duodenum could increase the risk of stent occlusion due to enteric particles, such as food or bacteria. In cases with asymptomatic duodenal invasion, there are limited data to guide the optimal drainage strategy, as transpapillary drainage is still feasible. Given the rapid progression of pancreatic cancer, avoiding transduodenal biliary bypass should be considered, especially in cases of duodenal involvement by the tumor (Fig. 1). In this study, the duodenal obstruction was mostly located proximal to the ampulla, and subsequent gastroduodenal stenting was required in 11 cases (19.6%), indicating disease progression despite ongoing palliative chemotherapy. Theoretically, in cases where the duodenal involvement is located distal to the ampulla, ERCP might be technically less challenging; however, stent patency should have been shorter with a higher rate of duodenobiliary reflux. Unfortunately, the study did not classify stent patency according to the specific location of duodenal involvement.

In summary, Takahara et al.¹ supported the use of EUS-HGS in patients with unresectable pancreatic cancer with asymptomatic duodenal invasion. This approach may reduce post-ERCP pancreatitis and potentially improve stent patency, compared with traditional ERCP techniques. However, further research is required to define the optimal biliary drainage strategy for this patient population when considering the impact of disease progression on stent durability.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: TC; Supervision: TR; Writing–original draft: TC; Writing–review & editing: TC, TR.

Fig. 1.

Proposed algorithm for biliary drainage in pancreatic cancer. PDAC, pancreatic ductal adenocarcinoma; EUS, endoscopic ultrasound; EUS-BD, EUS-guided biliary drainage; ERCP, endoscopic retrograde cholangiopancreatograpy; EUS-HGS, EUS-guided hepaticogastrostomy.

REFERENCES

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