Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound-guided primary biliary drainage for malignant distal biliary obstruction: a review

Approximately 70% of pancreatic cancers arising in the head of the pancreas cause malignant distal biliary obstruction. Therefore, biliary drainage is an important aspect of the management of these patients. Conventionally, the technique for relieving biliary obstruction has been endoscopic retrograde cholangiopancreatography (ERCP). When ERCP cannot provide biliary drainage, such as in cases of failed cannulation, duodenal obstruction, or altered anatomy (e.g., after gastric bypass), endoscopic ultrasound-guided biliary drainage (EUS-BD) has been recommended by the American Society for Gastrointestinal Endoscopy as the preferred technique over percutaneous transhepatic biliary drainage for relieving biliary obstruction. Recently, EUS-BD has been explored as the primary technique for relieving biliary obstruction. The proposed benefits include higher technical success, shorter procedural time, a lower risk of pancreatitis, and longer stent patency. However, the results of randomized controlled studies have been conflicting. Hence, the aim of this article is to review the evidence from randomized controlled trials comparing EUS-BD with ERCP as the primary method of biliary drainage for malignant distal biliary obstruction.