S2238 Effectiveness and Safety of EUS-Guided Gallbladder Drainage vs EUS-Guided Bile Duct Drainage in Patients With Malignant Biliary Obstruction After Failed ERCP: A Propensity-Score Matched International Multicenter Study

Introduction: It is unclear which is the best approach for the drainage of malignant distal biliary obstruction (MDBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). We compared endoscopic ultrasound (EUS)–guided gallbladder drainage (GBD) and EUS-guided choledocoduodenostomy (CDS) with lumen-apposing metal stents (LAMS) as rescue treatment in the case of ERCP failure. Methods: This was an international multicenter retrospective observational study at 28 tertiary-care centers through August 2024. Outcomes were compared using propensity score matching. Clinical success was the primary outcome, with technical success, adverse event (AE) rate and overall survival being the secondary outcomes. Results: Five hundred twenty-9 patients underwent EUS guided drainage of which 136 patients underwent EUS-GBD, and 393 patients underwent EUS-CDS. After 1-to-1 propensity score matching, 224 patients were selected (112 per group). Mean age was 76 years in both groups (P = 0.9) and 49 (43.7%) and 48 (42.8%) male patients were treated with EUS-GBD and EUS-CDS, respectively (P = 0.9). EUS-GBD and EUS-CDS had similar technical success (97.3% and 91%; P = 0.08) and clinical success rates (83% and 85.7%; P = 0.17). AE rate was 19.6% in the EUS-GBD group and 12.5% in the EUS-CDS group (P = 0.20), of which 10 (8.9%) and 7 (6.2%) severe AEs respectively (P = 0.61). Bleeding occurred in 7 patients (6.1%) after EUS-GBD and 3 patients (2.5%) after EUS-CDS whereas 5 infectious events were registered after EUS-GBD (4.4%) and 4 cases (3.5%) after EUS-CDS (P = 0.29). No treatment related deaths were observed. Median overall survival was 5 months (4-7) in the EUS-GBD group and 5.5 months (5-7) in the EUS-CDS group (P = 0.55). Conclusion: Our study showed that in patients with MDBO after failed ERCP, EUS-GBD or EUS-CDS were comparable with similar rates of efficacy and safety. EUS-GBD could represent an easy and safe option in MDBO patients without previous cholecystectomy and with a clear patency of the cystic duct.