Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis

Background and Aims: EUS-guided biliary drainage (EUS-BD) is increasingly used as an alternate therapeutic modality to percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction in patients who fail ERCP. We conducted a systematic review and meta-analysis to compare the efficacy and safety of these 2 procedures. Methods: We searched several databases from inception to September 4, 2016 to identify comparative studies evaluating the efficacy and safety of EUS-BD and PTBD. Primary outcomes of interest were the differences in technical success and postprocedure adverse events. Secondary outcomes of interest included clinical success, rate of reintervention, length of hospital stay, and cost comparison for these 2 procedures. Odds ratios (ORs) and standard mean difference were calculated for categorical and continuous variables, respectively. These were analyzed using random effects model of meta-analysis. Results: Nine studies with 483 patients were included in the final analysis. There was no difference in technical success between 2 procedures (OR, 1.78; 95% CI, .69-4.59; I-2 = 22%) but EUS-BD was associated with better clinical success (OR, .45; 95% CI, .23-.89; I-2 = 0%), fewer postprocedure adverse events (OR, .23; 95% CI, .12-.47; I-2 = 57%), and lower rate of reintervention (OR, .13; 95% CI, .07-.24; I-2 = 0%). There was no difference in length of hospital stay after the procedures, with a pooled standard mean difference of -.48 (95% CI, -1.13 to .16), but EUS-BD was more cost-effective, with a pooled standard mean difference of -.63 (95% CI, -1.06 to -.20). However, the latter 2 analyses were limited by considerable heterogeneity. Conclusions: When ERCP fails to achieve biliary drainage, EUS-guided interventions may be preferred over PTBD if adequate advanced endoscopy expertise and logistics are available. EUS-BD is associated with significantly better clinical success, lower rate of postprocedure adverse events, and fewer reinterventions.