Management of ERCP Failure in Malignant Biliary Obstruction: Comparative Effectiveness and Safety of EUS-Guided Gallbladder Drainage Versus Choledocoduodenostomy

Objectives It is unclear which is the best approach for the drainage of malignant distal biliary obstruction (MDBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). We compared endoscopic ultrasound (EUS)-guided gallbladder drainage (GBD) and EUS-guided choledocoduodenostomy (CDS) with lumen-apposing metal stents (LAMS) as rescue treatment in the case of ERCP failure.Methods This was an international multicenter retrospective observational study at 28 tertiary-care centers. Outcomes were compared using propensity score matching (PSM). Clinical success was the primary outcome, with technical success, adverse event (AE) rate, and overall survival being the secondary outcomes.Results Five hundred twenty-nine patients underwent EUS-guided drainage, of which 136 underwent EUS-GBD, and 393 underwent EUS-CDS. After 1-to-1 PSM, 112 patients per group were selected. EUS-GBD and EUS-CDS had similar technical success (97.3% and 91%; p = 0.08) and clinical success rates (83% and 85.7%; p = 0.17). AE rate was 19.6% in the EUS-GBD group and 12.5% in the EUS-CDS group (p = 0.20), of which 10 (8.9%) and 7 (6.2%) were severe AEs respectively (p = 0.61). Bleeding occurred in seven patients (6.1%) after EUS-GBD and three patients (2.5%) after EUS-CDS, whereas five infectious events were registered after EUS-GBD (4.4%) and four cases (3.5%) after EUS-CDS (p = 0.29). No treatment-related deaths were observed.Conclusion In patients with MDBO after failed ERCP, EUS-GBD or EUS-CDS were comparable with similar rates of efficacy and safety. EUS-GBD could represent an easy and safe option in MDBO patients without previous cholecystectomy and with a clear patency of the cystic duct.