Background Biliary (BO) and gastric outlet obstruction (GOO) frequently complicate pancreatic cancer, often delaying treatment. While EUS‐guided gastroenterostomy (EUS‐GE) is preferred over duodenal stenting for GOO, the optimal approach for biliary drainage (BD) between EUS‐guided choledochoduodenostomy (EUS‐CDS) and hepaticogastrostomy (EUS‐HGS) remains undefined. This systematic review and meta‐analysis aimed to identify the preferred BD strategy in patients undergoing EUS‐GE for concurrent GOO and BO. Methods We searched Medline, Scopus, and EMBASE up to February 2026. Studies were eligible if they reported outcomes of EUS‐CDS or EUS‐HGS in patients with malignant BO and concomitant GOO treated by EUS‐GE. Outcomes included technical and clinical success, stent dysfunction, and adverse events (AEs) analyzed using a random‐effects model. Results were reported as relative risks (RRs) with 95% confidence intervals (CIs). Results Five studies were included (128 patients; 45.5% female; mean age range 63.0–73.0 years), with 61 undergoing EUS‐CDS and 67 undergoing EUS‐HGS. Four studies were European, one American, and one prospective. Technical and clinical success rates were similar between groups (RR 0.96, 95% CI 0.83–1.11; I 2 = 0%; EUS‐CDS 94.5% vs. EUS‐HGS 96.4%), (RR 1.04, 95% CI 0.92–1.19; I 2 = 0%; EUS‐CDS 96.5% vs. EUS‐HGS 89.1%). Stent dysfunction was significantly higher in EUS‐CDS (RR 4.42, 95% CI 1.71–11.43; I 2 = 0%; EUS‐CDS 45.1% vs. EUS‐HGS 10.9%), while AEs were comparable (RR 1.14, 95% CI 0.24–5.50; I 2 = 40.8%; EUS‐CDS 10.7% vs. EUS‐HGS 16.0%). Conclusions EUS‐CDS and EUS‐HGS appear similarly safe and effective for managing malignant BO with concomitant GOO. However, EUS‐CDS carries a significantly higher risk of stent dysfunction, potentially delaying critical cancer treatment.
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Spadaccini et al. (2026) studied this question.
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