S2169 Comparative Outcomes of Endoscopic Ultrasound-Guided vs Endoscopic Retrograde Cholangiopancreatography Biliary Drainage in Malignant Biliary Obstruction: A Systematic Review and Meta-Analysis of RCTs

Introduction: Malignant biliary obstruction (MBO) is a serious complication of cancers involving the pancreas, bile ducts, or ampullary area. Endoscopic retrograde cholangiopancreatography (ERCP) remains the traditional approach to biliary drainage but is sometimes limited by tumor-related anatomical challenges and advanced tumor progression. Endoscopic ultrasound-guided biliary drainage (EUS-BD), initially used after failed ERCP, has gained traction as a primary option due to its potential to bypass these challenges. Methods: A meta-analysis was performed according to PRISMA guidelines. Seven randomized controlled trials (RCTs) comparing EUS-BD and ERCP-BD in patients with MBO were included. Primary outcome was technical success while secondary outcomes included clinical success, adverse events, procedural duration, hospital stay, stent patency, and need for subsequent reintervention. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with the I² statistic, and random- or fixed-effects models were applied accordingly. Results: Seven RCTs encompassing 621 patients (313 EUS-BD, 308 ERCP-BD) were analyzed. Technical success was significantly higher in the EUS-BD group (OR: 2.33; 95% CI: 1.32–4.13; P = 0.004). Clinical success was similar between groups (OR: 1.12; 95% CI: 0.65–1.95; P = 0.68). EUS-BD had shorter procedure time (MD: -6.89 minutes; P = 0.004) and shorter hospital stay (MD: -1.23 days; P = 0.006). Reintervention was significantly lower with EUS-BD (OR: 0.54; P = 0.02), while adverse event rates and stent patency showed no significant difference. Conclusion: EUS-BD had higher technical success and lower reintervention compared to ERCP-BD, suggesting it may be a viable first-line alternative, especially in complex cases. Despite similar safety and efficacy, the procedural and therapeutic advantages of EUS-BD; shorter duration and higher technical success, highlight its growing clinical relevance. Further large-scale, multicenter trials are needed to confirm long-term benefits and standardize outcome definitions.