Post written by Eduardo Cerchi Barbosa from the Department of Medicine, Evangelical University of Goiás, Anápolis, Brazil, and Gilmara Coelho Meine, MD, MSc, from the Division of Gastroenterology, Department of Internal Medicine, Feevale University, Novo Hamburgo, Brazil.

Periampullary cancers carry a poor prognosis and often result in malignant biliary obstruction (MBO). Despite technological advances, few cases are resectable at the time of diagnosis, and ERCP-guided biliary drainage (ERCP-BD) is the standard initial approach to relieve symptoms and improve survival. However, this procedure has limitations, including failure rates ranging from 0.5% to 16% and an adverse event (AE) rate of up to 30%.

Initially considered an alternative after unsuccessful ERCP-BD, EUS-guided biliary drainage (EUS-BD) has recently been proposed as a primary approach, potentially reducing the risk of AEs. Because of conflicting results in the literature, we conducted a systematic review and meta-analysis aiming to compare the efficacy and safety of EUS-BD versus that of ERCP-BD as primary treatments for MBO. In addition, we conducted subgroup analyses based on the etiology of MBO and the type of EUS-guided technique.

Our study, which included 6 randomized controlled trials (RCTs) and more than 570 patients, yielded valuable findings. EUS-BD was associated with significantly lower risks of reintervention, tumor ingrowth/overgrowth, and postprocedure pancreatitis, as well as a shorter hospital stay than with ERCP-BD. Yet, no significant differences were observed between EUS-BD and ERCP-BD in stent patency, procedure time, survival time, technical and clinical success rates, and risk of overall AEs and cholangitis.

Tumor ingrowth/overgrowth is a major cause of stent occlusion in patients with MBO, often requiring reintervention. Our meta-analysis showed that EUS-BD reduces the risk of stent occlusion and reintervention, probably because of its ability to establish a biliary bypass away from tumor invasion.

Furthermore, EUS-BD enables biliary drainage away from the ampulla and pancreatic duct, likely contributing to the lower risk of postprocedure pancreatitis. The reduction of these important AEs may have led to shorter hospital stay observed in the EUS-BD group.

EUS-BD has gained popularity over the past decade, particularly with the introduction of lumen-apposing metal stents (LAMSs), which allow for one-step access to the common bile duct and prevent stent migration. In our subgroup analysis, the use of LAMSs in choledochoduodenostomy significantly reduced procedure time and improved technical success compared with ERCP-BD.

In trials where pancreatic cancer was the predominant etiology of MBO, no significant differences were observed between EUS-BD and ERCP-BD. Conversely, in the subgroup of studies with a lower prevalence of pancreatic cancer (<65% of the cases), EUS-BD was associated with a reduced risk of overall AEs and need for reintervention than with ERCP-BD. Notably, none of the RCTs with lower rates of pancreatic cancer used LAMSs in choledochoduodenostomy, highlighting a potential area for future research.

In summary, EUS-BD and ERCP-BD were similarly effective as primary treatment options for MBO. However, EUS-BD was associated with a shorter hospital stay, as well as lower risk of reintervention, postprocedure pancreatitis, and tumor ingrowth/overgrowth. Further large RCTs are warranted to establish EUS-BD as a primary approach for MBO management.

Graphical abstract

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