Background: After a failed endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction (MBO), second-line drainage is performed with endoscopic ultrasound-guided biliary drainage (EUS-BD) or percutaneous transhepatic biliary drainage (PTBD). We compared their effectiveness, safety, and short-term survival. Methods: We conducted a single-center retrospective cohort of 101 adults with MBO after they had experienced a failed ERCP (EUS-BD n = 37; PTBD n = 64). Allocation was non-randomized and driven by operational availability. Baseline laboratory tests (complete blood count, platelets, and C-reactive protein) and derived indices (neutrophil-to-lymphocyte ratio NLR, platelet-to-lymphocyte ratio PLR, lymphocyte-to-monocyte ratio LMR, systemic immune-inflammation index SII, systemic inflammation response index SIRI, neutrophil-to-platelet score NPS, and lymphocyte-to-CRP ratio LCR) were compared. Outcomes that were a technical success include: an early biochemical response (bilirubin reduction), complications (Clavien–Dindo), length of stay (LOS), and overall survival (OS). Between-group comparisons used the two-sided Mann–Whitney U test (continuous) and Fisher’s exact (binary) test. Survival was assessed by the Kaplan–Meier estimator using log-rank testing. To address later adoption of EUS-BD, we also estimated a restricted mean survival time of 180 days (RMST₀–180) with 95% confidence intervals (CIs). Results: Baseline inflammatory markers and composite indices were similar; baseline total bilirubin was higher in PTBD. The technical success was 100% in both groups. Early biochemical response was 86. 5% after EUS-BD vs. 78. 1% after PTBD (p = 0. 43). Any complication occurred in 29. 7% vs. 12. 5% (p = 0. 04) ; major complications (Clavien–Dindo ≥ III) occurred in 10. 8% vs. 0% (p = 0. 02), respectively; and the LOS did not differ (p = 0. 21). OS favored EUS-BD (median 143 vs. 54 days and log-rank p = 0. 012). RMST₀–180 was 111. 1 days for EUS-BD vs. 71. 4 days for PTBD (difference + 39. 6 days; 95% CI 11. 3–65. 9). Conclusions: After a failed ERCP for MBO, EUS-BD and PTBD achieved universal technical success and similar early biochemical responses, but EUS-BD was associated with higher complication rates and a significantly longer six-month survival. These findings support the individualized selection balancing procedural risk with the anticipated survival benefit and highlight the need for prospective comparative studies.
Ciesielski et al. (Sat,) studied this question.