Outcomes predictors in endoscopic ultrasound-guided choledochoduodenostomy with lumen-apposing metal stent: a systematic review with meta-analysis

Introduction: EUS-guided choledochoduodenostomy (EUS-CDS) is a minimally invasive procedure used to treat malignant biliary obstruction (MBO) by the transduodenal placement of a lumen-apposing metal stent (LAMS) into the extrahepatic bile duct. In order to identify the factors that contribute to safe and effective EUS-CDS procedures using LAMS we performed a systematic review of the literature with meta-analysis. Methods: The methodology of our analysis was based on PRISMA recommendations. Electronic databases (Medline, Scopus, EMBASE) were searched up to November 2022. Full articles including patients with distal malignant biliary obstruction who underwent EUS-CDS using LAMS after failed ERCP were eligible. Random-effect meta-analysis was performed reporting pooled rates of Ttechnical success, clinical success, and adverse events were pooled by means of a random model. Multivariate meta-regression and subgroup analysis werewas performed to assess possible associations between the outcomes and selected variablesto assess the correlation between outcomes and different variables. The results were also stratified according to stent size. Results: Twelve studies with 845 patients were included in the meta-analysis. Pooled technical and clinical success rates were 96% (95%CI: 94%-98%; I2=52.29%) and 96% (95%CI: 95%-98%), respectively, with no significant association with baseline characteristics, such are sex, age, common bile duct (CBD) diameter and stent size. The pooled AE rate was 12% (95%CI: 8%-16%; I2=71.62%). The AE rate was significantly lower when using an 8x8mm stent as compared to a 6x8 mm LAMS (OR 0.59, 0.35-0.99; p=0.04), with no evidence of heterogeneity (I2=0%). Conclusion: EUS-CDS with LAMS is confirmed to be a safe and effective option for relief of MBO. The selection of appropriate stent size is crucial for achieving optimal safety outcomes.