S8 EUS-Guided Hepaticogastrostomy vs EUS-Guided Hepaticogastrostomy With Antegrade Stent Placement in Patients With Unresectable Malignant Distal Biliary Obstruction: A Meta-Analysis of Individual Patient Data

Introduction: In patients with malignant biliary obstruction (MBO) where endoscopic retrograde cholangiopancreatography has failed, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) serves as an important rescue procedure. This study aimed to compare the safety and effectiveness of EUS-HGS alone vs EUS-HGS combined with antegrade stenting (EUS-HGAS) in this patient population. Methods: A comprehensive literature search was performed in PubMed, SCOPUS, and Web of Science to identify studies comparing EUS-HGS with EUS-HGAS in patients with malignant biliary obstruction. The primary outcomes were the rate of recurrent biliary obstruction (RBO), the need for reinterventions, and time to RBO (TRBO). Secondary outcomes included technical success, clinical success, procedure duration, and the overall incidence of adverse events. Individual patient survival data for TRBO were extracted from Kaplan Meier curves and reconstructed using restricted mean survival time analysis. Results: Five observational studies comprising a total of 451 patients with MBO were included, with 239 patients receiving EUS-HGS and 212 undergoing EUS-HGAS. Compared to EUS-HGAS, EUS-HGS was associated with a significantly higher rate of RBO (RR = 3.52; 95% CI: 1.95–6.36; P < 0.0001) and reintervention (RR = 2.72; 95% CI: 1.30–5.69; P = 0.008). Additionally, TRBO was significantly longer in the EUS-HGAS group (median: 715 days vs 235 days; HR = 0.15; 95% CI: 0.03–0.83; P = 0.03). However, EUS-HGS was associated with a significantly shorter procedure time (MD = –4.01; 95% CI: –7.77 to –0.24; P = 0.04). No significant differences were found between the 2 groups in terms of technical success, clinical success, or overall adverse events. Conclusion: In patients with MBO following failed endoscopic retrograde cholangiopancreatography, EUS-HGAS appears to offer superior outcomes compared to EUS-HGS alone, with significantly lower incidence of recurrent biliary obstruction, reintervention, and longer TRBO. Although EUS-HGS is associated with a shorter procedure time, both techniques demonstrate comparable technical and clinical success rates, as well as similar safety profiles. These findings suggest that EUS-HGAS may be the preferred approach when feasible.