Endoscopic ultrasound-guided gallbladder drainage for distal malignant biliary obstruction: It's not the tool – but knowing which one to use!

10.1055/a-2837-9342 Every time a novel approach is put forward in medicine, it pushes us to rethink our current techniques and frame this new indication within the existing framework. This is also true for endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) in the context of biliary drainage for patients with distal malignant biliary obstruction (DMBO). More and more retrospective data are being published on this approach [ 1 ] [ 2 ] and, although feasibility has been proven, this new treatment option is still regarded as controversial and seems to divide the hepatopancreaticobiliary endoscopy community. We cannot however ignore the fact that systematic reviews of these retrospective data are showing promising rates of clinical success (≥50% reduction in bilirubin) of around 88%–90% [ 3 ]. A multitude of questions however remain, including how EUS-GBD compares with the more established techniques such as EUS-guided choledochoduodenostomy (EUS-CDS) and, more importantly, in which patients we could consider EUS-GBD for bile duct drainage. In the current international multicenter retrospective study by Debourdeau et al. [ 4 ], the authors aimed to answer one of these questions by comparing EUS-GBD with EUS-CDS in patients after failed endoscopic retrograde cholangiopancreatography (ERCP). Using 1 : 1 nearest-neighbor propensity score matching, 100 patients in each group were compared, showing a reduction in baseline differences pre- and postmatching. EUS-GBD seemed to result in a higher 12-month biliary reintervention-free survival rate compared with EUS-CDS (86.2% vs. 63.8%; P = 0.01), with near perfect technical success rates for both groups. For EUS-GBD however, a trend towards lower clinical success (80.5% vs. 90.6%, P = 0.08) was also seen. Based on these results, the authors suggest that EUS-GBD should be considered earlier in the treatment algorithm following ERCP failure, rather than being reserved solely as a rescue strategy. Limitations to the current study mainly seem related to the retrospective design, nonuniform treatment selection, and the lack of information on other biliary drainage techniques employed in the study interval. “EUS-GBD for DMBO has several technical advantages over EUS-CDS ... the effectiveness of biliary drainage with EUS-GBD should however be one of our major concerns ...” EUS-GBD for DMBO has several technical advantages over EUS-CDS: (1) it can be employed regardless of the common bile duct diameter; (2) the technique itself is highly reproducible with established safety in the context of acute cholecystitis; (3) lumen-apposing metal stents (LAMSs) not involved in the temporary recall can be used; and (4) EUS-GBD can be performed without the need for more complex drainage techniques, such as are required for transgastric or intrahepatic EUS-guided biliary drainage techniques . The effectiveness of biliary drainage with EUS-GBD should however be one of our major concerns when it is used in the context of DMBO. In the current study, there was a clear trend towards lower clinical success, based on bilirubin levels, when compared with EUS-CDS. Looking at patient-level data, we can see that, in 71.0% of patients treated with EUS-GBD, a transgastric route was used and overall duodenal stricture rates where high (40.0%). In the last few years, we have learnt that both of these factors may compromise LAMS patency [ 5 ] [ 6 ] and alternative approaches should be considered when aiming for effective long-term biliary drainage in such situations [ 6 ]. In addition, EUS-CDS as a comparator warrants scrutiny, as this technique itself is plagued by high dysfunction rates in excess of 30%–55% in real-life datasets and one could wonder whether EUS-CDS is the most optimal sounding board for a novel drainage modality [ 7 ]. For patients with duodenal strictures or gastric outlet obstruction in particular, current evidence suggests that EUS-guided hepaticogastrostomy (EUS-HGS) should be considered the preferred technique, although randomized confirmation is awaited [ 6 ]. Adding to effectiveness concerns and complexity is the question as to whether we should select EUS-guided transmural or transpapillary stenting following ERCP failure. A recent trial from India, which randomized inoperable patients with MBO and ERCP failure to either EUS-CDS/EUS-HGS or EUS-guided antegrade stent placement, showed superior stent patency at 3 and 6 months for antegrade stenting [ 8 ]. These data suggest that, when technically feasible, a more physiological drainage route should ideally be pursued. When reading the current study, we furthermore wonder about the usage of these intrahepatic techniques during the study interval and wonder whether EUS-HGS or EUS-guided antegrade stent placement were considered options in every participating center. Providing a broad repertoire of endoscopic bile duct drainage modalities is crucial in the care of patients with hepatopancreaticobiliary disorders and additional drainage options, such as EUS-GBD, should be welcomed when other more established endoscopic techniques, such as EUS-guided antegrade stent placement, rendezvous techniques, and EUS-HGS, have been exhausted. Ultimately, more data on EUS-GBD within the DMBO scenario are required and familiarity with the full spectrum of bile duct drainage modalities should be a prerequisite, which should be regarded as equally important as selecting the appropriate tool for the appropriate scenario. Publication History Article published online: 30 June 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany Refers to: CHOLEBLADEUS: long-term results of endoscopic ultrasound-guided gallbladder versus bile duct drainage of malignant biliary obstruction after failed ERCP: a propensity-matched study Endoscopy eFirst DOI: 10.1055/a-2837-9342