Combined EUS and ERCP in patients with malignant distal biliary obstruction is associated with reduced time to oncological therapy compared to ERCP and sampling alone.

Objectives: Standard ERCP sampling techniques for pancreaticobiliary malignancy have modest yields that could lead to delays in treatment. We aimed to evaluate whether combining EUS guided tissue acquisition (EUS-TA) with ERCP versus ERCP alone at the time of index procedure improved time to first outpatient evaluation and oncological treatment.

Methods: All patients without a prior pathological diagnosis who underwent index ERCP at Leeds Teaching Hospitals NHS Trust, United Kingdom, for malignant distal biliary obstruction from 2015 to 2020 were considered.

Results: A total of 292 patients were included, of whom 74.7% (n = 202) underwent EUS-TA/ERCP. A combined approach was more likely to establish a positive diagnosis (96.5% (n = 195) vs 57.8% (n = 52), p < 0.01) and less likely to require further sampling procedures (2.0% (n = 4) vs 17.8% (n = 16), p < 0.01). Mean times to first outpatient evaluation (16.9 vs 24.5 days (p = 0.01)) and oncological treatment (55.1 vs 79.3 days (p = 0.03)) were significantly shorter in the EUS-TA/ERCP group. A third (n = 86) of patients with a positive diagnosis did not receive oncological/surgical treatment.

Conclusions: In our cohort of patients, a combined approach was associated with improved diagnostic yield, reduced need for repeat sampling procedures and reduced time to evaluation and treatment, with similar therapeutic success and adverse event rates. Careful multidisciplinary discussion is recommended to avoid performing unnecessary EUS procedures on patients who will not benefit from further treatment.