S2287 Primary EUS-Guided Biliary Drainage Compared to ERCP for Malignant Biliary Obstruction: A Meta-Analysis of Randomized Controlled Trials

Introduction: Endoscopic ultrasound guided biliary drainage (EUS-BD) is an emerging technique for biliary decompression in malignant biliary obstruction (MBO). EUS-BD has been historically used as rescue therapy when ERCP fails. However, recent studies suggested its efficacy in the initial management of MBO. We aimed to compare the efficacy and safety of EUS vs ERCP when used as the primary modality for biliary decompression in MBO. Methods: A systematic search of MEDLINE, Embase, and Cochrane databases, from inception to May 25, 2025, was conducted for randomized controlled trials (RCTs) comparing EUS and ERCP as the primary modality for MBO. Primary outcomes were technical and clinical success rates. Secondary outcomes included stent patency, reintervention, risk of post-procedure pancreatitis (PPP), overall adverse events (AEs), cholangitis, tumor in/overgrowth, procedure time, length of hospital stay (LOS), and survival time. Risk ratios (RR) with 95% confidence intervals (CI) were calculated for dichotomous outcomes, using a random-effects model. Heterogeneity was assessed using I2 statistics. Technical success was defined as the successful placement of stent, whereas clinical success defined as ≥50% reduction in serum bilirubin. Results: A total of 8 RCTs were included (807 patients). There were no significant differences between both groups in technical success (RR = 1.06; 95% CI: 0.96-1.17) or clinical success (RR = 1.02; 95% CI: 0.98-1.06). However, EUS-BD was associated with lower risk of PPP (RR = 0.19; 95% CI: 0.08-0.46) compared to ERCP with no heterogeneity between studies (I2 = 0%). There was no statistically significant difference in terms of stent patency (MD = 8.2; 95% CI: -40.7-57.1), over all AEs (RR = 0.65; 95% CI: 0.23-1.87) or cholangitis (RR = 1.19; 95% CI: 0.39-3.61). However, the risk of reintervention (RR = 0.53; 95% CI: 0.29-0.96) and tumor in/overgrowth (RR = 0.28; 95% CI: 0.11-0.70) were significantly lower in the EUS-BD group. Additionally, EUS-BD group had shorter procedure time (MD = -7.69; 95% CI: -13.89 to -1.49) and hospital stay (MD = -1.03; 95% CI: -1.53 to -0.53) compared to ERCP-BD. Conclusion: Our meta-analysis demonstrates that EUS-BD has similar technical and clinical success to ERCP in managing MBO, with lower rates of PPP as expected. However, these data are from expert endoscopists, and future real-world studies looking at learning curves of EUS-BD and surgical outcomes following EUS-BD are needed prior to considering EUS-BD as first line therapy for MBO.