Endoscopic ultrasound-guided rendezvous vs precut for difficult biliary cannulation: Updated meta-analysis

Background and study aims: Difficult biliary cannulation (DBC) remains a significant challenge in endoscopic retrograde cholangiopancreatography (ERCP). When cannulation fails, precut techniques are widely used as rescue techniques. Endoscopic ultrasound-guided rendezvous (EUS-RV) is increasingly used by experts as an alternative to precut for cannulating the bile duct. However, there is limited literature comparing these two techniques. This systematic review and meta-analysis aimed to compare effectiveness and safety of EUS-RV versus precut techniques for biliary access in DBC. Methods: A systematic search was conducted across PubMed, Embase, and Cochrane Library databases up to April 2025. Studies comparing EUS-RV and precut techniques in adult patients with DBC were included. Data were pooled using a random-effects model. Primary outcome was technical success rates; secondary outcome was adverse event (AE) rates. P < 0.05 was considered statistically significant. Results: Five studies (two randomized controlled trials and three retrospective cohorts) comprising 875 patients were included. Pooled technical success was higher with EUS-RV compared with precut (95.9% vs. 91.4%; relative risk [RR] 1.06; 95% confidence interval [CI] 1.00-1.12; P = 0.036). AE rates were 7.7% for EUS-RV and 11.2% for precut, with no statistically significant difference (RR, 0.78; 95% CI 0.46-1.31; P = 0.349). Conclusions: EUS-RV is associated with higher technical success rates compared with precut techniques for rescue biliary cannulation after failed standard ERCP, with a comparable safety profile. These findings suggest that EUS-RV may represent at least a valuable alternative rescue strategy when expertise is available; however, further trials are needed to assess its safety, procedure duration, and learning curve.