Endoscopic ultrasound-guided gallbladder drainage for jaundice: Second-line strategy with a strict entry selection

We extend our sincere congratulations to Debourdeau et al. for their GALLBLADEUS Study,¹ a pioneering retrospective comparative analysis of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) versus gallbladder drainage (EUS-GBD) following failed endoscopic retrograde cholangiopancreatography (ERCP) for managing distal malignant biliary obstruction (dMBO).

While commending the authors for their objective and balanced reporting of results, this letter aims to dissect and underscore critical points to accurately convey the study's conclusions and avoid a superficial interpretation suggesting equivalence between EUS-CDS and EUS-GBD.

First, the two study arms appear mutually exclusive, as EUS-GBD seemingly acted as a third-line rescue in patients with failed ERCP and anticipated more challenging EUS-CDS (see significantly lower median bile duct diameter). Second, EUS-GBD exhibited a slower reduction in bilirubin levels at 7 and 30 days compared to EUS-CDS, despite similar chemotherapy access. Moreover, the higher rate of adverse events in the EUS-CDS group mainly stems from dysfunction events, occurring in a population where about 50% of patients presented with duodenal stenosis, an increasingly recognized risk factor for EUS-CDS dysfunction,^2-4 if not a proper contraindication to EUS-CDS. The study's exclusive focus on transgastric EUS-GBD, likely chosen to avoid the problem of duodenal invasion and mitigate tumor interference, further complicates generalizability. Finally, it is important to remember that EUS-GBD for jaundice inherently relies on a careful assessment of a patent's cystic duct.

Consequently, while the GALLBLADEUS study implies EUS-GBD as a viable option for selected patients with dMBO where ERCP and EUS-CDS are unfeasible, it falls short of suggesting equivalence between techniques and lots of prerequisites need to be ascertained.

Notably, EUS-GBD remains untested against EUS-hepaticogastrostomy, which exhibits promising performance, especially in the case of duodenal infiltration.^{3, 5}

The game in the realm of EUS-guided biliary drainage strategies remains open, but our comprehension of the players involved is certainly growing deeper.

Authors declare no conflict of interest for this article.