EUS- versus ERCP-guided biliary drainage for malignant biliary obstruction: evidence from randomized controlled studies

Background: Endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD) is the first-line technique for the management of malignant biliary obstruction. Previous evidence demonstrated that endoscopic ultrasound-guided biliary drainage (EUS-BD) is technically safe and feasible, and EUS-BD has been used as the alternative palliative treatment when ERCP fails. We aimed to compare the therapeutic efficacies and procedure-associated complications of EUS-BD and ERCP as the first treatment option. Methods: Studies comparing efficacies and complications of EUS-BD and ERCP-BD for the management of malignant biliary obstruction published before January 25, 2019 were searched. The patient characteristics, variables regarding to the therapeutic efficacies and procedure-associated complications of EUS-BD were compared to that of ERCP-BD by meta-analyses. Results: After screening 821 studies, three randomized clinical trials (RCTs) comparing the therapeutic efficacies and complications of EUS-BD and ERCP-BD for the palliative treatment of malignant obstructive jaundice were included. No significant difference was found between EUS-BD and ERCP-BD regarding to the technical success rate, clinical success rate, procedure time, and stent patency at 3 months and 6 months. The incidence of overall adverse events was also similar between the two groups. EUS-BD showed higher frequency of stent patency at 12 months. In addition, EUS-BD showed significant decreased incidence of procedure-associated pancreatitis [odds ratio (OR) =0.08, 95% confidence intervals (CI): 0.01 to 0.62, P=0.02) and reintervention rate (OR =0.25, 95% CI: 0.12 to 0.54, P=0.0004). Conclusions: Compared to ERCP-BD, EUS-BD showed equivalent therapeutic efficacy with decreased incidence of pancreatitis and reintervention rate. EUS-BD, like ERCP-BD, could be the first-line technique for the management of malignant biliary obstruction.