Evaluation of clinical success and adverse events with endoscopic ultrasound-guided biliary drainage (EUS-BD) compared to percutaneous transhepatic biliary drainage (PTBD) after failed ERCP in malignant biliary obstruction: A systematic review and me

4186 Background: ERCP fails to achieve biliary decompression in ~3–10% of malignant biliary obstruction cases. Rescue drainage is typically performed using percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound–guided biliary drainage (EUS-BD). Although PTBD is widely available, it carries substantial morbidity, requires external catheters, and is associated with recurrent infections and reduced quality of life. EUS-BD offers internal drainage with favorable outcomes across established techniques, but comparative evidence versus PTBD remains limited. We performed a systematic review and meta-analysis comparing EUS-BD and PTBD after failed ERCP in malignant biliary obstruction. Methods: This review followed PRISMA guidelines. PubMed, Google Scholar, and ScienceDirect were searched using a comprehensive strategy. Comparative studies evaluating EUS-BD versus PTBD and reporting technical success (TS: bile duct puncture with stent/catheter placed in the intended position), clinical success (CS: > 50% bilirubin reduction at 2 weeks), adverse events (AD: graded as per the ASGE endoscopic AE severity lexicon), and reintervention (RN) were included. The data was analysed using the Meta, Metadata and the Metafor packages of R Studio. The Mantel-Haenszel method and the Inverse variance method were utilized to analyse the odds ratio for TS, CS, AD, and RN. The I 2 test was used to assess the heterogeneity of the studies. Results: Twenty-six studies were included. EUS-BD was associated with higher clinical success (OR 2.46, 95% CI 1.47–4.11) and lower odds of adverse events (OR 0.38, 95% CI 0.26–0.57) and reintervention (OR 0.19, 95% CI 0.09–0.42). Technical success did not differ significantly between groups (OR 0.49, 95% CI 0.21–1.13). Conclusions: Compared with PTBD, EUS-BD is associated with improved clinical success and fewer adverse events and reinterventions after failed ERCP in malignant biliary obstruction. Where expertise is available, EUS-BD may be favored over PTBD. Prospective randomized trials are needed to confirm these findings and support broader adoption. Pooled outcomes for EUS-BD vs PTBD. Outcome/Metric Comparison Effect measure Estimate (OR) 95% CI (lower) 95% CI (upper) p-value Direction/Interpretation Clinical success EUS-BD vs PTBD OR 2.46 1.47 4.11 0.1328 Favors EUS-BD (higher odds of success) Adverse events EUS-BD vs PTBD OR 0.38 0.26 0.57 0.1923 Favors EUS-BD (lower odds of adverse events) Reintervention EUS-BD vs PTBD OR 0.19 0.09 0.42 0.0003 Favors EUS-BD (lower odds of reintervention) Technical success EUS-BD vs PTBD OR 0.49 0.21 1.13 0.3321 Not statistically significant