Endoscopic Ultrasound (EUS)-Guided Gallbladder Drainage vs EUS-Guided Bile Duct Drainage After Failed ERCP for Malignant Biliary Obstruction: An International Multicenter Study

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Aims Endoscopic ultrasound (EUS)–guided gallbladder (GB) drainage and EUS-guided bile duct (BD) drainage with lumen-apposing metal stents are alternative approaches to endoscopic retrograde cholangiopancreatography (ERCP). We compared EUS-GB and EUS-BD as second line therapies in the setting of failed ERCP for malignant biliary obstruction (MBO) [ 1 ] [ 2 ] [ 3 ]. Methods This was an international multicenter retrospective observational study at 28 tertiary-care centers through August 2024. Consecutive patients with MBO who underwent EUS-GB or EUS-BD as second line therapy with LAMS placement were included. Outcomes were compared using propensity score matching. Cohorts were compared using Chi-square, Mann-Whitney tests, and logistic regression. Results Five hundred and twenty-nine patients (254 males; average age 73±12 years) underwent EUS guided drainage where 136 patients underwent EUS GB drainage, and 393 patients underwent EUS BD drainage. Most patients developed MBO from pancreatic cancer (79%). AXIOS stents were used in most cases (91%) compared to SPAXUS (9%). Overall, technical success was reported in 96% of cases and clinical success in 87% of cases. After 1-to-1 propensity score matching, 224 patients were selected (112 per group). EUS-GB showed higher technical success compared to EUS-BD (97% vs 92%, P=0.045). However, EUS-GB showed lower clinical success compared to EUS-BD (74% vs 86%, P=0.030). No statistical differences were reported in adverse events for EUS-GB and EUS-BD including bleeding (6% vs 3%, P=0.196), perforation (0% vs 2%, P=0.155), stent occlusion (5% vs 4%, P=0.528), stent migration (2% vs 1%, P=0.561), and acute pancreatitis (2% vs 0%, P=0.155), respectively. Stent type was not associated with technical success (AXIOS 94% vs SPAXUS 94%, P=0.983) or clinical success (AXIOS 78% vs SPAXUS 88%, P=0.188). On univariate analysis, EUS-BD was not a significant predictor of technical success (P=0.059) but had higher odds of clinical success compared to EUS-GD (OR=2.10, 95% CL 1.07-4.13, P=0.032). univariate analysis. Conclusions In patients with MBO, EUS-GB and EUS-BD are reasonable therapeutic alternatives in the setting of failed ERCP. However, EUS-BD may offer higher clinical success when compared to EUS-GB. Publication History Article published online: 27 March 2025 © 2025. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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