Endoscopic Ultrasound-Guided Choledochoduodenostomy: A Technical Review

Endoscopic retrograde cholangiopancreatography (ERCP) has been the standard treatment option for distal biliary obstruction. However, ERCP is known to fail in 5 to 15% cases. EUS-guided biliary drainage (EUS-BD) is an effective alternative to ERCP in patients with distal biliary obstruction. Among EUS-BD techniques, EUS-guided choledochoduodenostomy (EUS-CDS) enables transluminal drainage from the duodenal bulb into the common bile duct. Emerging evidence suggests that EUS-CDS may have a role as a primary therapeutic role in relieving distal biliary obstruction, especially in patients anticipated to have a difficult prolonged ERCP procedure, which increases the risks of complications. The technique to perform the EUS-CDS procedure is evolving, resulting in superior technical and clinical outcomes with reduced complications. This review presents a comprehensive technical overview of EUS-CDS, discusses clinical indications, patient selection, stent and device choices, procedural nuances, clinical outcomes, adverse events, salvage techniques, and training benchmarks.