Endoscopic Ultrasound-Guided Biliary Drainage in Altered Gastrointestinal Anatomy: A Systematic Review and Meta-Analysis

Summary

This study presents a meta-analysis comparing endoscopic ultrasound-guided biliary drainage (EUS-BD) and endoscopic retrograde cholangiopancreatography (ERCP) for biliary obstruction in patients with altered gastrointestinal anatomy.

Abstract

ERCP intubation is often difficult in patients with biliary obstruction and changes in gastrointestinal structure, such as after Roux-en-Y or Billroth II surgery. EUS-BD is an alternative method. This meta-analysis should systematically compare the efficacy and safety of EUS-BD and ERCP in these patients. Studies were retrieved from PubMed, Embase, Web of Science, and the Cochrane Library from 2011 to 2026. Original studies comparing EUS-BD and ERCP in patients with biliary obstruction and a history of gastrointestinal reconstruction surgery were included. Two researchers independently carried out literature screening, data extraction, and quality evaluation. A meta-analysis was conducted using Review Manager. The main outcome measures are technical success rate, clinical success rate, adverse events, and procedure time. A total of 6 studies involving 572 patients (201 in the EUS-BD group and 371 in the ERCP group) were included in the technical success analysis. The meta-analysis demonstrated that the pooled technical success rate was 90.5% (182/201) for the EUS-BD group and 70.4% (261/371) for the ERCP group, yielding an odds ratio (OR) of 3.60 (95% CI: 2.12–6.13; p < 0.00001). For clinical success, the pooled odds ratio was 3.52 (95% CI: 2.07–5.98; p < 0.00001), demonstrating a statistically significant advantage over ERCP. In terms of safety, there was no difference in the overall incidence of adverse events between the two groups (25.9% vs. 20.5%; OR: 1.54, 95% CI: 0.97–2.44). In patients with biliary obstruction and surgically altered gastrointestinal anatomy, EUS-BD was associated with higher pooled technical and clinical success rates in available observational studies, along with shorter procedure time than ERCP. However, current evidence remains insufficient to establish a definitive difference in overall adverse events. EUS-BD represents a viable and highly effective alternative drainage modality for this challenging population, particularly when standard ERCP is anticipated to be technically demanding.

Introduction

Biliary obstruction is an obstructive condition. Pathologically, the biliary system is blocked¹. The etiologies include pancreatic diseases, cholangiocarcinoma, ampullary cancer, gallstones, surgical conditions, etc². The core pathological change is bile stasis and high pressure in the bile duct, which leads to a series of symptoms and complications³. Endoscopic interventional techniques such as ERCP-BD and EUS-BD are clinically used⁴. ERCP-BD is the main palliative treatment method for biliary obstruction, which can relieve symptoms and prolong the survival period

Protocol

Guidelines and official logging

The reporting complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement; the completed PRISMA checklist is provided in the Supplementary Materials. The study protocol was prospectively registered in PROSPERO (CRD420261297962). All the tools or materials used for this study are listed in the Table of Materials.

Search strategy

Three reviewers independently performed the comprehensive electronic search in duplicate, covering records from January 1st, 2011, to J....

Results

Study selection and trial characteristics

A total of 528 records were initially identified through the systematic search^{16,17,18,19,20,21}. Following the removal of 37 duplicates, 491 records underwent title and abstract screening, resulting in the exclusion of 234 studies. A full-t.......

Discussion

In this systematic review and meta-analysis of 6 observational cohort studies involving over 578 patients, success rates, safety profiles, and time-related outcomes between EUS-BD and ERCP-BD were compared for biliary tract obstruction in patients with altered gastrointestinal anatomy. The pooled analyses yielded the following key findings: 1) EUS-BD demonstrated significantly higher technical and clinical success rates, alongside a shorter procedure time, when compared to ERCP; 2) Although EUS-BD showed a numerically hi.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Cochrane Library	Wiley	URL: https://www.cochranelibrary.com; Database accessed up to Jan 1, 2026	Literature search
Embase	Elsevier	URL: https://www.embase.com; Database accessed up to Jan 1, 2026	Literature search
EndNote	Clarivate	URL: https://endnote.com; Version 21	Reference and bibliography management
PROSPERO	Centre for Reviews and Dissemination, University of York	URL: https://www.crd.york.ac.uk/prospero; Identifier: CRD420261297962	Protocol registration
PubMed	U.S. National Library of Medicine	URL: https://pubmed.ncbi.nlm.nih.gov; Database accessed up to Jan 1, 2026	Literature search
Review Manager (RevMan)	The Cochrane Collaboration	URL: https://revman.cochrane.org; Version 5.4	Meta-analysis and forest plot
Web of Science	Clarivate	URL: https://www.webofscience.com; Database accessed up to Jan 1, 2026	Literature search