Comparative Outcomes of Endoscopic and Percutaneous Biliary Drainage in Malignant Biliary Obstruction: An Updated Systematic Review and Meta-Analysis.

Background: Malignant biliary obstruction (MBO) frequently necessitates biliary decompression, either preoperatively or for palliation. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are commonly employed, but comparative outcome data are conflicting. Methods: We conducted a systematic review and meta-analysis of PubMed, EMBASE, CENTRAL, and Google Scholar through January 31, 2025, in accordance with PRISMA guidelines. Eligible studies included randomized trials and comparative observational cohorts evaluating ERCP versus PTBD for MBO. The primary outcome was clinical success; secondary outcomes included technical success, adverse events, mortality, reintervention rates, and hospital stay. Results: Twenty-two studies (6 randomized trials, 16 observational) comprising 9520 patients (ERCP: 6864; PTBD: 2,656) were included. PTBD had higher technical success (OR 0.47; 95% CI, 0.25–0.89) but greater adverse events (OR 5.08; 95% CI, 2.17–11.90). ERCP required fewer reinterventions (OR 0.16; 95% CI, 0.06–0.40). Clinical success and mortality were similar. Hospital stay and survival varied substantially across studies, precluding pooled estimates. Conclusion: PTBD offers higher technical success but at the cost of increased adverse events and reinterventions. ERCP demonstrates a more favorable safety profile. In the absence of a clear survival benefit, procedure selection should be individualized based on patient condition, anatomy, and expertise.