Comparison of 4 first-line endoscopic biliary drainage modalities in distal malignant biliary obstruction: A systematic review and network meta-analysis

Background and objectivesEUS-guided biliary drainage is a potential alternative to endoscopic retrograde cholangiopancreatography (ERCP) for distal malignant biliary obstruction (DMBO). However, its role as a primary intervention remains uncertain. This study compares the clinical outcomes of 4 primary endoscopic drainage modalities: ERCP, EUS-hepaticogastrostomy (HGS), EUS-choledochoduodenostomy (CDS) with lumen-apposing metal stent (LAMS), and EUS-CDS with self-expandable metal stents (SEMSs).MethodsThe literature was searched up until July 2024. A network meta-analysis of 5 randomized controlled trials and 3 comparative studies, including 796 patients (444 ERCP, 180 EUS-CDS-LAMS, 116 EUS-CDS-SEMS, 56 EUS-HGS), was conducted. Outcomes assessed included clinical success, technical success, procedural time, adverse events, reintervention rates, and stent patency.ResultsClinical success was comparable across all modalities. EUS-CDS-LAMS demonstrated higher technical success compared with ERCP (odds ratio [OR], 3.95; 95% confidence interval [CI], 1.54-10.12) and EUS-CDS-SEMS (OR, 4.37; 95% CI, 1.03-18.55). EUS-CDS-LAMS also had a shorter procedural time compared with ERCP (standardized mean difference, -11.67; 95% CI, -15.66 to -7.68), EUS-CDS-SEMS, and EUS-HGS. Adverse event rates were similar across all groups. EUS-HGS had fewer reinterventions compared with ERCP (OR, 0.20; 95% CI, 0.08-0.52) and EUS-CDS-LAMS (OR, 0.22; 95% CI, 0.07-0.74). At 6 months, stent patency rates were 88.7% for EUS-HGS, 84.5% for EUS-CDS-SEMS, 73.1% for EUS-CDS-LAMS, and 64.8% for ERCP.ConclusionsClinical success and adverse event rates were comparable among modalities. EUS-CDS-LAMS showed superior technical success and shorter procedural time. In contrast, EUS-HGS showed fewer reinterventions and better stent patency than ERCP.