Long-term Efficacy of EUS-BD versus ERCP as initial biliary drainage for Malignant Distal Biliary Obstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background Current guidelines suggest endoscopic retrograde cholangiopancreatography (ERCP) with self-expandable metal stent (SEMS) placement as initial biliary drainage for malignant distal biliary obstruction (MDBO). However, ERCP is technically challenging or unfeasible in patients with duodenal obstruction or postsurgical anatomical changes. EUS-guided biliary drainage (EUS-BD) offers another available therapy, but previous studies mainly assessed short-term endpoints, with long-term efficacy remaining inconclusive. We updated the meta-analysis of randomized controlled trials (RCTs) to assess the long-term effectiveness of EUS-BD and ERCP as initial biliary drainage for MDBO. Methods We comprehensively searched PubMed, CENTRAL, and Embase up to June 1, 2026, for RCTs evaluating EUS-BD and ERCP as initial biliary drainage for patients with MDBO. We applied TSA and GRADE to evaluate the pooled estimate’s stability and evidence strength. Results This meta-analysis included six RCTs and 739 patients. EUS-BD demonstrated a significantly lower reintervention rate compared with ERCP (RR 0.62, 95% CI 0.42 to 0.92; P = 0.02, I 2 = 0%, moderate certainty of evidence). Moreover, EUS-BD showed a significantly lower postprocedural pancreatitis rate (RR 0.18, 95% CI 0.06 to 0.51; P = 0.001, I 2 = 0%) and a shorter hospital stay (MD −0.92 days, 95% CI −1.42 to −0.43; P = 0.0003, I 2 = 0%), with no significant differences in technical and clinical success, stent patency time, or overall adverse events. Conclusion In patients with MDBO, EUS-BD demonstrates a lower risk of reintervention compared with ERCP, while achieving comparable technical and clinical success. In centers with abundant EUS expertise, EUS-BD may serve as an alternative biliary drainage strategy for MDBO.