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Systematic Review and Meta-analysis Endoscopic ultrasound-guided biliary drainage versus endoscopic retrograde cholangiopancreatography biliary drainage in the palliative management of malignant distal biliary obstruction: an updated systematic review and meta-analysis of randomized controlled trials
Spyros Peppas1orcid, Advait Suvarnakar2orcid, Bara A. Abujaber1orcid, Nadera Altork1orcid, Amer Arman1orcid, Sayel Alzraikat1orcid, Akram I. Ahmad3orcid, Camille Boustani4orcid, Won Kyoo Cho2,5orcid

DOI: https://doi.org/10.5946/ce.2024.155
Published online: May 9, 2025

1Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA

2Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC, USA

3Divsion of Gastroenterology and Hepatology, Weston, FL, USA

4Division of Gastroenterology and Hepatology, MedStar Georgetown University Medical Center, Washington, DC, USA

5Divsion of Gastroenterology and Hepatology, INOVA Health System, Leesburg, VA, USA

Correspondence: Spyros Peppas Department of Medicine, MedStar Washington Hospital Center, 110 Irving Street NW, Washington, DC, 20010, USA E-mail: peppas.spyros@gmail.com
• Received: June 12, 2024   • Revised: November 4, 2024   • Accepted: November 24, 2024

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Background/Aims:
    Evidence suggests comparable outcomes between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in the biliary drainage of malignant distal biliary obstruction (MDBO). We conducted an updated systematic review and meta-analysis comparing the EUS with ERCP in the management of MDBO.
  • Methods:
    We performed a literature search using the Medline, Embase and Cochrane databases, including randomized controlled trials comparing EUS and ERCP in patients with MDBO. Meta-analysis was performed using the random-effects model using the STATA ver. 17.0 software.
  • Results:
    Both procedures were comparable in technical (risk ratio [RR], 1.01; 95% confidence interval [CI], 0.78–1.30) and clinical (RR, 1.10; 95% CI, 0.85–1.41) success. No difference was identified in total adverse events (RR, 0.75; 95% CI, 0.42–1.35), acute cholangitis (RR, 0.84; 95% CI, 0.43–1.62), stent patency (RR, 1.13; 95% CI, 0.87–1.46) and mean stent patency time (mean difference, –0.01; 95% CI: –0.21 to 0.19). ERCP was associated with a higher risk of procedure-related pancreatitis (RR, 0.17; 95% CI, 0.04–0.68) and statistically non-significant higher risk for reintervention (RR, 0.61; 95% CI, 0.37–1.01).
  • Conclusions:
    Although EUS and ERCP were comparable in terms of efficacy and safety, ERCP was associated with a higher risk of procedure-related pancreatitis and reintervention, with the latter finding not reaching statistical significance.
  • Keywords: Bile duct obstruction; Endoscopic retrograde cholangiopancreatography; Endosonography; Self expandable metal stent
Malignant distal biliary obstruction (MDBO) is a common sequela in the progression of periampullary cancers and is associated with worse quality of life.1 Current practice recommends transpapillary stent placement with endoscopic retrograde cholangiopancreatography (ERCP) as the primary modality for palliative management of MDBO in patients with locally advanced, unresectable pancreato-biliary malignancy.2 Although clinical and technical success rates with this approach are high in expertise centers, it has been associated with significant adverse events, including post-ERCP pancreatitis and cholangitis, in 2% to 34% of all performed ERCP procedures.3 Furthermore, in patients with MDBO with previous intra-abdominal surgeries or duodenal invasion, cannulation can be challenging, increasing the risk for adverse events in the post-procedural period.4
Endoscopic ultrasound (EUS) has advanced from a diagnostic and imaging modality into a minimally invasive approach and EUS-guided biliary drainage (EUS-BD) has been introduced as an alternative to percutaneous transhepatic biliary drainage after a failed ERCP in patients with MDBO.5,6 EUS-BD can be classified into two main categories based on the route of approach: choledochoduodenostomy and hepaticogastrostomy.3 In observational and randomized controlled trials (RCTs), EUS-BD showed comparable efficacy in terms of clinical and technical success with an acceptable safety profile compared to ERCP.7-11 Additionally, EUS-BD carries some advantages over ERCP, including avoidance of papillary injury during cannulation, no tumor ingrowth as the stent is placed away from the tumor, and shorter procedural time.12 However, despite the promising use of EUS-BD, the lack of standardization and universal expertise prevents and complicates the widespread adoption of the technique.
Within the last year, two new RCTs have demonstrated the non-inferiority of EUS-BD compared to ERCP with a favorable safety profile. Therefore, the aim of this systematic review and meta-analysis was to compare the efficacy and safety between EUS-BD and ERCP in relieving MDBO.
Our study protocol was registered with the International Prospective Register of Systematic Reviews (CRD42023486730). The current meta-analysis was performed following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).13
Inclusion and exclusion criteria
We searched for RCTs involving adult patients with a diagnosis of a borderline resectable and locally advanced or unresectable periampullary cancer with MDBO that directly compared EUS-BD and ERCP-BD as primary treatment options. All articles irrespective of publication type were considered for inclusion. In the case of multiple studies involving the same population, data from the most recent or most comprehensive one were included.
Exclusion criteria were applied to non-randomized studies, case series, case reports, reviews, letters, or editorials. We also excluded studies that evaluated EUS-BD as a rescue treatment after a failed ERCP procedure. Finally, we excluded studies that did not report data on our prespecified outcomes of interest.
Search strategy
Published studies were identified using the Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception till November 2023. Search algorithms included the following terms: (“EUS-guided biliary drainage” OR “EUS” OR “endoscopic ultrasound” OR “choledochoduodenostomy” OR “hepaticogastrostomy”) AND (“ERCP” OR “endoscopic retrograde cholangiopancreatography”) AND (“distal malignant biliary obstruction” OR “biliary decompression” OR “biliary drainage”).
Selection process and data extraction
Two investigators (S.P. and A.S.) independently reviewed titles/abstracts of studies identified in the search, and excluded those that were clearly irrelevant. We excluded editorials, notes, congress abstracts, and studies that were not conducted in humans. We manually screened the reference lists of relevant systematic reviews and meta-analyses. The full texts of the selected articles were analyzed to determine whether it contained information on the topic of interest. Their reference lists were hand-searched to identify further relevant publications. The following data were extracted from the included studies: authors, publication year, sample, age, sex, etiology of the malignancy, procedure time, type of stent, EUS-BD approach, technical and clinical success rate, adverse events, stent patency rates, stent dysfunction, need for reintervention and follow-up time. We did not apply any language restriction in the selection of eligible studies. Disagreements in the selection process and data extraction were resolved by consensus with the assistance of another team member (N.A.)
Outcomes
The primary outcomes of our study included (1) clinical and technical success of each treatment modality and (2) stent patency rates. To maximize the scope of data collection, the above outcome measures were defined using the definitions in the original studies. Secondary outcomes included (1) overall adverse events, (2) procedure-related pancreatitis, (3) cholangitis, (4) need for reintervention, and (5) mean stent patency time.
Quality assessment
Quality assessment of the included studies was performed independently by two reviewers (B.A., N.A.) by using the Cochrane Risk of Bias 2.0 tool for RCTs.14 The following five domains were assessed (1) bias arising from the randomization process (random sequence generation and allocation concealment), (2) bias due to deviations from intended interventions (allocation concealment), (3) bias due to missing outcome data (if data for all outcomes available for all randomized participants), (4) bias in measurement of the outcome (if the method of measuring the outcome was appropriate, or measurements could be differed between the two groups), and (5) bias in the selection of the reported result (if data that produced this result were analyzed in accordance with a prespecified analysis plan). Any disagreements were discussed among team members and resolved via consensus.
Statistical analysis
We calculated and compared the weighted pooled risk ratios (RRs) of primary and secondary outcomes with their corresponding 95% confidence intervals (CIs), and p-values were collected. A p-value <0.05 was considered statistically significant. The mean stent patency time between EUS-BD and ERCP-BD were compared by using the Hedge’s g test. The corresponding forest plots were generated for the graphical presentation of clinical outcomes. Heterogeneity between trials was quantified by measuring inconsistency using the Higgins I2 index.15 Values above 75% indicated high heterogeneity. The DerSimonian-Laird random-effects model of meta-analysis was applied to give a more conservative estimate of the effect. STATA ver. 17.0 (StataCorp.,) was used as the statistical software for all analyses.
Search results
Literature search identified a total of 2,573 abstracts after removal of duplicates, 81 of whose full texts were retrieved and were examined in detail. The reason of exclusion of relevant articles included (1) single-arm observational studies (n=21), (2) observational studies with comparator group (n=9), (3) reviews or meta-analyses (n=23), (4) case reports or series (n=12), (5) editorials or comments (n=6), or (6) studies that evaluated EUS after a failed attempt of ERCP (n=5). Finally, five RCTs were included in the analysis.7-11 The schematic diagram of the study selection process is presented in Figure 1.
Study and population characteristics
All five studies included in the analysis were RCTs with a total of 526 patients, of which 263 underwent EUS-BD and 263 ERCP-BD for palliative management of MDBO. Two studies were multicenter,9,10 while the rest of the studies were single-center with two being performed in Asia7,8 and one in the United States of America (USA).11 The quality assessment of the studies included in the analysis is presented separately in Supplementary Table 1. Overall, the included studies were open-label RCTs and considered as having a moderate risk of bias. The majority of patients were males (55.9%). For patients undergoing EUS-BD, one study reported the sole usage of a fully covered self-expandable metal stent (CSEMS),11 two used a lumen-apposing metal stent (LAMS),9,10 one used a partially CSEMS,8 while another used fully or partially CSEMS and uncovered metal stent7. In the ERCP-BD group, one study used fully CSEMS,11 three used partially CSEMS,7-9 while one used either a fully or partially CSEMS or uncovered metal stent.10 Choledochoduodenostomy was the standard EUS approach in four studies,8-11 and one study used hepaticogastrostomy in patients with periampullary duodenal invasion with compromised duodenal bulb, or surgically altered anatomy.7 The primary diagnosis and indication for intervention was pancreatic cancer in 447 patients (85.0%). All studies provided information on follow-up periods, with two of them defining it as one year or until the occurrence of a composite outcome (death or resolution of symptoms),9,10 while in the other three studies, the median follow-up time ranged from 121–190 days.7,8,11 Τhe baseline demographic data and the outcomes of the included studies are presented in Tables 1, 2 respectively.
Meta-analysis of outcomes

1) Technical and clinical success

Overall, five studies reported data regarding technical and clinical success for both EUS-BD and ERCP-BD. EUS-BD was technically successful in 93.2% (n=245/263) compared to 85.2% (n=218/256) of the patients undergoing ERCP-BD; however, no statistically significant difference was observed between the two procedures (RR, 1.10; 95% CI, 0.85–1.41, I2=0%) (Fig. 2). EUS-BD demonstrated clinical success in 91.1% (n=235/258) of the patients, while clinical success rate in the ERCP-BD group was 90.4% (n=226/250) with no superiority of one procedure over the other (RR, 1.01; 95% CI, 0.78–1.30; I2=0%) (Fig. 3).

2) Total adverse events

Most common adverse events included bleeding, perforation, acute pancreatitis, acute cholangitis, bile peritonitis and stent obstruction. Overall, peri- and postoperative complications occurred in 17.9% of patients who underwent an EUS-BD (n=47/265) compared to 24.6% (n=63/256) in those who had an ERCP; however, this lower adverse event rate was not statistically significant (RR, 0.75; 95% CI, 0.42–1.35; I2=36.8%) (Fig. 4).

3) Procedure-related pancreatitis

No events (n=0) of procedure-related pancreatitis were reported in the EUS-BD group, while 6.3% (n=16/256) of patients in the ERCP-BD group were diagnosed with the complication postoperatively. EUS demonstrated a significantly lower risk of acute pancreatitis in the postoperative period compared to ERCP (RR, 0.17; 95% CI, 0.04–0.68) (Fig. 5).

4) Acute cholangitis

The frequency of acute cholangitis was 6.5% (n=17/263) in the EUS-BD group and 7.8% (n=20/256) in the ERCP-BD group. Treatment with either EUS or ERCP did not result in a higher risk for acute cholangitis postoperatively (RR, 0.84; 95% CI, 0.43–1.62; I2=0%) (Fig. 6).

5) Need for reintervention

In this analysis, data from five studies were analyzed. Most common reasons for reinterventions included stent dysfunction (e.g., from tumor overgrowth, or stent migration) and acute cholangitis. Although the reintervention rate was lower in the EUS-BD group (11.2%, n=29/263) compared to the ERCP-BD group (18.8%, n=48/256), the result did not reach statistical significance (RR, 0.61; 95% CI, 0.37–1.01, I2=0%) (Fig. 7).

6) Stent patency

Stent patency rates were reported for different follow-up time intervals in the included studies. Specifically, two studies assessed stent patency at 1 year,9,10 one at 6 months,7 and the other two studies at different follow-up periods as presented in Table 1.8,11 There was no significant difference in the frequency of stent patency between the EUS-BD (88.9%, n=233/262) and ERCP-BD (79.6%, n=205/255) groups (RR, 1.13; 95% CI, 0.87–1.46; I2=0%) (Fig. 8). Four studies provided information on the mean patency time.8-11 The analysis showed similar mean patency times between EUS-BD and ERCP-BD group (199 vs. 195 days; standardized mead difference, –0.01; 95% CI, –0.21 to 0.19) (Fig. 9).
This updated systematic review and meta-analysis compared the EUS- and ERCP-guided biliary drainage with stent placement procedures as primary therapeutic modalities in the palliative management of MDBO. Our study demonstrated that both approaches were comparable in terms of technical and clinical efficacy without a significant difference in the stent patency in the follow-up period. Although total adverse event rates, cholangitis events, and mean stent patency time were similar between EUS-BD and ERCP-BD groups, the ERCP approach was associated with a significantly higher risk for procedure-related pancreatitis, along with a trend towards a more frequent need for reintervention for management of postoperative complications, a finding that did not reach statistical significance in our analysis.
The findings of our study are in agreement with the results of a recent systematic review and meta-analysis by Khouri et al.16 which showed no statistically significant difference in technical and clinical success between EUS-BD and ERCP-BD. Furthermore, overall adverse event rates were comparable between the two therapeutic modalities with a higher risk of procedure-related pancreatitis and reintervention in the ERCP-BD group.16
In our study we demonstrated that the ERCP-BD group had higher odds for reintervention compared to patients undergoing the EUS approach (18.8% vs. 11.2%, respectively), a which did not reach statistical significance. A plausible hypothesis for this finding could be the avoidance of the malignant stricture with the transmural approach adopted by the EUS which leads to a decreased risk of stent dysfunction from tumor overgrowth.3,10,17 Additionally, there was no difference in stent patency rates and time between these two modalities. The selection of the stent, and especially the use of covered versus partially covered or uncovered one, may play a role in the need for reintervention. A recent systematic review and meta-analysis demonstrated a longer time to recurrent biliary obstruction in patients with MDBO treated with CSEMS, along with lower rates of recurrent biliary obstruction in a subgroup analysis of patients with MDBO caused by pancreatic cancer.18
In our study, the pooled incidence rate of post-ERCP pancreatitis was 6.3% which is in accordance with the current literature and previous systematic reviews and meta-analyses.19-22 The rates of post-ERCP pancreatitis can exceed 10% in patients with challenging cannulation especially with prolonged duration or multiple attempts to achieve cannulation.23 Post-ERCP pancreatitis is a significant source of morbidity, leading to longer hospital stays and increased healthcare resource utilization in the USA.21 Since EUS is not associated with pancreatitis, it could be regarded as a primary option for patients at high risk for developing post-ERCP pancreatitis. Furthermore, compared to previous meta-analyses, we conducted a separate analysis of postoperative acute cholangitis and demonstrated no increased risk associated with either modality.
Although there was no significant difference in total adverse event rates between EUS-BD and ERCP-BD, peritonitis is a complication that should be considered within a few days after the procedure in patients undergoing EUS-BD.5 This relatively rare complication has an incidence rate of approximately 1% and is primarily caused by bile leakage, which can lead to sepsis through bacterial translocation from the abdominal cavity into the bloodstream.24 In our study, a total of two cases of bile peritonitis were reported in the EUS-BD group. The low incidence can be attributed to the high expertise of the advanced endoscopists and the reduced technical challenges during the procedure. However, bile peritonitis can be a fatal complication, making it important to formulate a prevention strategy. This includes careful selection of eligible patients, considering the type of stent used, and the presence of duodenal obstruction.24
A major limitation for the widespread adoption of EUS-BD in the management of MDBO includes the lack of standardization compared to the ERCP technique.25 Currently, there is no consensus on the preferred biliary access, including transduodenal or transgastric approach.3 Although there is evidence showing that the transduodenal approach is associated with less adverse events, other reports demonstrate no significant differences in outcomes between the two approaches.5,26,27 We were unable to conduct a subgroup analysis based on the EUS approach used because only one study included patients who underwent EUS-choledochoduodenostomy, which ultimately demonstrated no differences in efficacy, safety, or overall survival compared to EUS-CDS.7
Besides the biliary access, lack of a uniform approach is also observed in the accessories used, and especially in stent selection. Khoury et al.16 demonstrated some interesting findings in the subgroup analysis they conducted according to the type of stent used for EUS-BD. LAMS with EUS-BD was associated with significantly higher technical success and shorter procedural time compared with ERCP, a difference that was not observed with EUS-BD using SEMS compared with ERCP. Interestingly, studies conducted with SEMS showed lower reintervention and higher stent patency rates compared with ERCP, whereas there was no statistically significant difference between EUS-BD with LAMS and ERCP.16 Thus, although technical success of EUS-BD with LAMS was better than that of ERCP, the higher risk for reintervention and lower stent patency rates should be taken into consideration in terms of cost efficiency and widespread adoption of this stent type.
One of the main strengths of our study is that it followed a strict protocol with well-defined search strategy, inclusion criteria, outcomes, and statistical analysis methods. This is an updated meta-analysis of RCTs that includes the most recent and high-quality evidence in the endoscopic management of MDBO. We aimed to include every potential outcome, and especially adverse events in the final analysis (e.g., acute cholangitis rate, mean stent patency time) to draw more robust conclusions in the comparison between EUS-BD and ERCP-BD. Lastly, there was low to moderate heterogeneity in all the analyses of the present study.
Our study has several limitations. Firstly, all RCTs included in the analysis were single-blinded which conveys a high probability for detection and performance bias. Additionally, no information was provided for the stent type selection, an important aspect for reintervention rates. Stent dysfunction is more common in covered stents than partially covered or uncovered, and this could account for the higher reintervention rates in the ERCP-BD group. Another limitation of our study was that only two of the included studies were of multicenter design; thus, our results may not be generalizable to implement the widespread of EUS-BD as a primary therapeutic modality. Although EUS-BD is known for fewer complications, the procedures in the included studies were performed in centers with high expertise and advanced endoscopic technology. This is especially important as it can explain the lack of statistically significant difference on the adverse event rate between EUS and ERCP in our study. Furthermore, we did not adjust for the lack of standardization of EUS technique including differences in biliary access, transmural tract dilatation, equipment used and expertise between centers, an element that could also account for the heterogeneity observed in our analysis. Lastly, there was variation in the definition of clinical success across the studies, with differences in time and degree of bilirubin decrease, although we did not observe heterogeneity in the final analysis.
In conclusion, this systematic review and meta-analysis showed similar efficacy, safety and stent patency between EUS-BD and ERCP-BD as primary modalities in the palliative management of MDBO. However, the ERCP approach was associated with significantly higher rates of procedure-related pancreatitis as well as a higher rate of reintervention, which did not reach statistical significance. The lack of statistical significance may be attributed to the small sample size of our meta-analysis, as well as the fact that the procedures were conducted in high-volume centers with significant expertise, which minimizes the risk of adverse events and procedure-related complications. Thus, future meta-analyses, especially with the more widespread adoption and standardization of EUS, could include studies from centers with less expertise and subsequently identify differences in the rates of reinterventions between these two modalities. The EUS approach seems to be a better option in patients with difficult cannulation and altered surgical anatomy to minimize the potential risks associated with ERCP in such cases. Future studies are needed to further assess the efficacy and safety of EUS and to develop more cost-effective techniques and training programs that will lead to its widespread adoption.
Supplementary Table 1. Quality and risk of bias assessment of included studies using the revised Cochrane Risk of Bias tool for randomized trials (RoB 2).
ce-2024-155-Supplementary-Table-1.pdf
Supplementary materials related to this article can be found online at https://doi.org/10.5946/ce.2024.155.
Fig. 1.
Flow diagram showing the selection process of articles included in the systematic review and meta-analysis.
ce-2024-155f1.jpg
Fig. 2.
Forest plot of included studies comparing the technical efficacy between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
ce-2024-155f2.jpg
Fig. 3.
Forest plot of included studies comparing the clinical efficacy between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
ce-2024-155f3.jpg
Fig. 4.
Forest plot of included studies comparing the total adverse events between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
ce-2024-155f4.jpg
Fig. 5.
Forest plot of included studies comparing incidences of procedure-related pancreatitis between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
ce-2024-155f5.jpg
Fig. 6.
Forest plot of included studies comparing the need for reintervention between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
ce-2024-155f6.jpg
Fig. 7.
Forest plot of included studies comparing incidences of acute cholangitis between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
ce-2024-155f7.jpg
Fig. 8.
Forest plot of included studies comparing the stent patency between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
ce-2024-155f8.jpg
Fig. 9.
Forest plot of included studies comparing the mean stent patency time between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. SMD, standardized mean difference; CI, confidence interval.
ce-2024-155f9.jpg
ce-2024-155f10.jpg
Table 1.
Baseline demographic characteristics of the studies included in the analysis
Study Year published Study design No. of patients
 Age (yr)
 Male
 Type of stent
 EUS approach
 Procedure time (min)
 Pancreatic cancer
 Follow-up time
EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD CD HG EUS-BD ERCP-BD EUS-BD ERCP-BD
Bang et al.11 2018 RCT 33 34 69.4±12.6 69.2±11.6 17 (51.5) 23 (67.6) Fully CSEMS Fully CSEMS 33 0 25 (18–30) 25 (18–30) 33 (100) 31 (91.2) 190 Days
Paik et al.7 2018 RCT 64 61 64.8 (40–90) 68.4 (46–88) 41 26 Fully or partially CSEMS, uncovered metal stent Partially CSEMS NR NR 5 (3–12) 5 (3–12) 38 (59.4) 40 (65.5) 155 (100–234) days
Park et al.8 2018 RCT 14 14 66.8±8.0 65.4±9.3 9 8 Partially CSEMS Partially CSEMS 14 0 43±24 43±24 14 (100) 12 (85.7) EUS 95 (78–210) days, ERCP 147 (73–273) days
Teoh et al.9 2023 RCT 79 83 75.1±11.9 72.1±12.4 32 41 LAMS Partially CSEMS 79 0 10 (5.75–18) 10 (5.75–18) 76 (96.2) 73 (87.9) Until 1 year or symptoms resolve
Chen et al.10 2023 RCT 73 71 73.3±10.4 70.6±11.2 47 (64.4) 50 (74.4) LAMS Partially or fully CSEMS, uncove-red metal stent 73 0 14.0±11.4 23.1±15.6 63 (86.3) 67 (94.3) Until 1 year or until death

Values are presented as mean±standard deviation, number (%), or median (interquartile range) unless otherwise indicated.

EUS-BD, endoscopic ultrasound biliary drainage; ERCP-BD, endoscopic retrograde cholangiopancreatography biliary drainage; CD, choledochoduodenostomy; HG, hepaticogastrostomy; RCT, randomized controlled trial; CSEMS, covered self-expandable metal stent; NR, not reported.

Table 2.
Outcomes of the studies included in the analysis
Study Year published Technical success
 Clinical success
 Adverse events
 Procedure-related pancreatitis
 Acute cholangitis
 Bile peritonitis
 Total reintervention
 Stent patency
 Stent patency time (day)
EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD ERCP-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD
Bang et al.11 2018 30 (90.9) 32 (94.1) 32 (97.0) 31 (91.2) 7 (21.2) 5 (14.7) 0 1 (2.9) 4 (6.2) 6 (9.8) 1 (2.9) 0 1 (3.0) 1 (2.9) 32 (97.0) 33 (97.1) 181.6±65.9 155.0±114.5
Paik et al.7 2018 60 (93.8) 55 (90.2) 54 (90.0) 52 (94.5) 7 (10.9) 24 (39.3) 0 9 (14.7) 5 (6.3) 4 (5.3) 1 (1.5) 0 10 (15.6) 26 (42.6) 54 (85.1) 30 (48.9) 208 165
Park et al.8 2018 13 (92.8) 14 (100) 13 (100) 13 (92.8) 0 (0) 0 (0) 0 0 8 (11.0) 9 (11.8) 0 0 2 (15.4) 4 (30.8) 12 (85.7) 9 (69.2) 379±55 403±84
Teoh et al.9 2023 76 (96.2) 58 (76.3) 74 (93.7) 69 (90.8) 13 (16.5) 13 (17.1) 0 2 (2.6) 0 1 (2.9) 0 0 9 (11.3) 10 (12.7) 69 (91.1) 67 (88.1) 183.2±131.3 161.3±136.0
Chen et al.10 2023 66 (90.1) 59 (83.1) 62 (84.9) 61 (85.9) 20 (27.4) 21 (29.6) 0 4 (5.6) 0 0 (0) 0 0 7 (9.6) 7 (9.9) 67 (90.4) 64 (90.1) 163.9±128.4 200.1±135.5

Values are presented as median (interquartile range), number (%), or mean±standard deviation.

EUS-BD, endoscopic ultrasound biliary drainage; ERC-BD, endoscopic retrograde cholangiopancreatography biliary drainage.

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      Endoscopic ultrasound-guided biliary drainage versus endoscopic retrograde cholangiopancreatography biliary drainage in the palliative management of malignant distal biliary obstruction: an updated systematic review and meta-analysis of randomized controlled trials
      Image Image Image Image Image Image Image Image Image Image
      Fig. 1. Flow diagram showing the selection process of articles included in the systematic review and meta-analysis.
      Fig. 2. Forest plot of included studies comparing the technical efficacy between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
      Fig. 3. Forest plot of included studies comparing the clinical efficacy between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
      Fig. 4. Forest plot of included studies comparing the total adverse events between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
      Fig. 5. Forest plot of included studies comparing incidences of procedure-related pancreatitis between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
      Fig. 6. Forest plot of included studies comparing the need for reintervention between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
      Fig. 7. Forest plot of included studies comparing incidences of acute cholangitis between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
      Fig. 8. Forest plot of included studies comparing the stent patency between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. CI, confidence interval.
      Fig. 9. Forest plot of included studies comparing the mean stent patency time between endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage. SMD, standardized mean difference; CI, confidence interval.
      Graphical abstract

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      Graphical abstract

      Endoscopic ultrasound-guided biliary drainage versus endoscopic retrograde cholangiopancreatography biliary drainage in the palliative management of malignant distal biliary obstruction: an updated systematic review and meta-analysis of randomized controlled trials
      Study Year published Study design No. of patients
      		 Age (yr)
      		 Male
      		 Type of stent
      		 EUS approach
      		 Procedure time (min)
      		 Pancreatic cancer
      		 Follow-up time
      EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD CD HG EUS-BD ERCP-BD EUS-BD ERCP-BD
      Bang et al.11 2018 RCT 33 34 69.4±12.6 69.2±11.6 17 (51.5) 23 (67.6) Fully CSEMS Fully CSEMS 33 0 25 (18–30) 25 (18–30) 33 (100) 31 (91.2) 190 Days
      Paik et al.7 2018 RCT 64 61 64.8 (40–90) 68.4 (46–88) 41 26 Fully or partially CSEMS, uncovered metal stent Partially CSEMS NR NR 5 (3–12) 5 (3–12) 38 (59.4) 40 (65.5) 155 (100–234) days
      Park et al.8 2018 RCT 14 14 66.8±8.0 65.4±9.3 9 8 Partially CSEMS Partially CSEMS 14 0 43±24 43±24 14 (100) 12 (85.7) EUS 95 (78–210) days, ERCP 147 (73–273) days
      Teoh et al.9 2023 RCT 79 83 75.1±11.9 72.1±12.4 32 41 LAMS Partially CSEMS 79 0 10 (5.75–18) 10 (5.75–18) 76 (96.2) 73 (87.9) Until 1 year or symptoms resolve
      Chen et al.10 2023 RCT 73 71 73.3±10.4 70.6±11.2 47 (64.4) 50 (74.4) LAMS Partially or fully CSEMS, uncove-red metal stent 73 0 14.0±11.4 23.1±15.6 63 (86.3) 67 (94.3) Until 1 year or until death
      Study Year published Technical success
      		 Clinical success
      		 Adverse events
      		 Procedure-related pancreatitis
      		 Acute cholangitis
      		 Bile peritonitis
      		 Total reintervention
      		 Stent patency
      		 Stent patency time (day)
      EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD ERCP-BD ERCP-BD EUS-BD ERCP-BD EUS-BD ERCP-BD
      Bang et al.11 2018 30 (90.9) 32 (94.1) 32 (97.0) 31 (91.2) 7 (21.2) 5 (14.7) 0 1 (2.9) 4 (6.2) 6 (9.8) 1 (2.9) 0 1 (3.0) 1 (2.9) 32 (97.0) 33 (97.1) 181.6±65.9 155.0±114.5
      Paik et al.7 2018 60 (93.8) 55 (90.2) 54 (90.0) 52 (94.5) 7 (10.9) 24 (39.3) 0 9 (14.7) 5 (6.3) 4 (5.3) 1 (1.5) 0 10 (15.6) 26 (42.6) 54 (85.1) 30 (48.9) 208 165
      Park et al.8 2018 13 (92.8) 14 (100) 13 (100) 13 (92.8) 0 (0) 0 (0) 0 0 8 (11.0) 9 (11.8) 0 0 2 (15.4) 4 (30.8) 12 (85.7) 9 (69.2) 379±55 403±84
      Teoh et al.9 2023 76 (96.2) 58 (76.3) 74 (93.7) 69 (90.8) 13 (16.5) 13 (17.1) 0 2 (2.6) 0 1 (2.9) 0 0 9 (11.3) 10 (12.7) 69 (91.1) 67 (88.1) 183.2±131.3 161.3±136.0
      Chen et al.10 2023 66 (90.1) 59 (83.1) 62 (84.9) 61 (85.9) 20 (27.4) 21 (29.6) 0 4 (5.6) 0 0 (0) 0 0 7 (9.6) 7 (9.9) 67 (90.4) 64 (90.1) 163.9±128.4 200.1±135.5
      Table 1. Baseline demographic characteristics of the studies included in the analysis

      Values are presented as mean±standard deviation, number (%), or median (interquartile range) unless otherwise indicated.

      EUS-BD, endoscopic ultrasound biliary drainage; ERCP-BD, endoscopic retrograde cholangiopancreatography biliary drainage; CD, choledochoduodenostomy; HG, hepaticogastrostomy; RCT, randomized controlled trial; CSEMS, covered self-expandable metal stent; NR, not reported.

      Table 2. Outcomes of the studies included in the analysis

      Values are presented as median (interquartile range), number (%), or mean±standard deviation.

      EUS-BD, endoscopic ultrasound biliary drainage; ERC-BD, endoscopic retrograde cholangiopancreatography biliary drainage.

      Table 1.

      Table 2.

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