Endoscopic ultrasound-guided choledochoduodenostomy vs Endoscopic Retrograde Cholangiopancreatography for malignant distal biliary obstruction: a meta-analysis of randomized controlled trials

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Background Endoscopic retrograde cholangiopancreatography (ERCP) using transpapillary stenting is the standard primary modality for biliary drainage in malignant distal biliary obstruction (MDBO), but it is associated with post-procedure pancreatitis and other related complications. Endoscopic ultrasound–guided choledochoduodenostomy (EUS-CDS) has been developed as an alternative first-line, papilla-bypassing approach. This meta-analysis compared the safety and efficacy of primary EUS-CDS with ERCP in patients with MDBO. Methods We searched PubMed, Embase and Cochrane Library from inception until February 2026 for randomized controlled trials comparing primary EUS-CDS with ERCP in adults with MDBO, following PRISMA guidelines. Random-effects meta-analysis assessed post-procedural pancreatitis (primary outcome), technical success, clinical success, stent patency, mortality and adverse events. Results Three multicenter trials encompassing 519 patients (263 EUS-CDS, 256 ERCP) were assessed. Post-procedural pancreatitis was significantly reduced with EUS-CDS (RR 0.20; 95% CI 0.08–0.52; p=0.018; I² = 0%). There were no significant differences in the technical success(RR 1.18; 95% CI 0.99–1.41), clinical success (RR 1.00; 95% CI 0.94–1.08), stent patency (RR 1.03; 95% CI 0.98–1.08) or mortality (RR 1.05; 95% CI 0.74–1.51). Overall, procedural adverse events were slightly lower with EUS-CDS (RR 0.95; 95% CI 0.91–1.00; p=0.041). Conclusions Primary EUS-CDS is associated with a significantly lower rate of post-procedural pancreatitis than ERCP, without compromising its efficacy in MDBO. These data on EUS-CDS further support its role as a first-line drainage strategy in appropriately selected patients.

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