S2252 Endoscopic Ultrasound Versus ERCP for Biliary Drainage Prior to Surgery: A Systematic Review and Meta-Analysis of Surgical Outcomes

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is usually used for preoperative biliary drainage (PBD) but carries risks of post-ERCP pancreatitis and stent-related complications, potentially delaying surgery. EUS-guided biliary drainage may reduce complications, but its impact on surgical exploration remains unclear. We conducted a systematic review and meta-analysis comparing the safety and efficacy of EUS and ERCP for PBD in terms of post-operative outcomes. Methods: A systematic review of the literature from PubMed, EMBASE, and Scopus was conducted through April 2025, for studies comparing outcomes after pancreaticoduodenectomy and other surgeries when PBD is performed with EUS or ERCP. Outcomes of interest were surgical complications, need for reintervention, length of stay, and post-operative mortality. Standard meta-analysis methods were followed using the random-effects model. Treatment effect estimates were expressed as odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI). Heterogeneity was assessed using the I2% statistic. Results: Four retrospective studies were included that reported on 546 patients (54.4% men). 185 patients underwent EUS while 361 underwent ERCP. Three studies were multicenter, while on was single center. There were trends towards decreased odds of post-operative complications (OR 0.55; 95% CI [0.28, 1.09], P = 0.08) and pancreatic fistula formation (OR 0.73; 95% CI [0.42, 1.25], P = 0.25) in the EUS group compared to the ERCP group that were not statistically significant. There was a statistically significant decrease in mean length of stay (MD -2.96; 95% CI [-4.92, -0.99], P = 0.003) and odds of need for endoscopic reintervention (OR 0.29; 95% CI [0.09, 0.87], P = 0.03) in the EUS group. There was no statistically significant difference in the odds of need for surgical reintervention (OR 1.60; 95% CI [0.49, 5.40], P = 0.44) or post-operative mortality (OR 2.01; 95% CI [0.44, 9.17], P = 0.37) between the 2 groups. Conclusion: Our meta-analysis demonstrates that in terms of post-surgical outcomes, EUS is a feasible and potentially safe alternative to ERCP for PBD. It was associated with shorter lengths of stay and reduced repeat endoscopic interventions without increasing the risk of post-operative complications or mortality. Further prospective studies are required to clarify the utility of EUS in PBD and to establish its comparative safety and efficacy relative to ERCP.