EUS-Guided Gallbladder vs Bile Duct Drainage for Malignant Biliary Obstruction: Multicenter Trial

The study you are referring to is an international multicenter trial that compared two endoscopic ultrasound (EUS)-guided procedures for managing distal malignant biliary obstruction (MBO): EUS-guided gallbladder drainage (EUS-GBD) and EUS-guided choledochoduodenostomy (EUS-CDS). Traditionally, such conditions are managed using endoscopic retrograde cholangiopancreatography (ERCP), but this study explored alternative primary drainage strategies using EUS-guided techniques with lumen-apposing metal stents.

Key Details of the Study:

1. Study Design:

• Retrospective observational trial conducted across 28 tertiary care centers.
• Timeframe: April 2017 to August 2024.

2. Participants:

• A total of 291 patients with distal malignant biliary obstruction were included.
• The majority of cases (84%) were due to pancreatic cancer.
• 82 patients underwent EUS-GBD, while 209 underwent EUS-CDS.

3. Methodology:

• To minimize selection bias, the study employed 1-to-1 propensity score matching, resulting in 154 matched patients (77 in each group).
• Both procedures utilized lumen-apposing metal stents.

4. Outcomes Compared:

• Primary Outcome: Clinical success (defined as effective biliary drainage and resolution of symptoms).
• Secondary Outcomes: Technical success, adverse events, and overall survival.

Results:

1. Technical Success:

• EUS-GBD: 96%.
• EUS-CDS: 99%.
• Both procedures showed high and comparable rates of technical success.

2. Clinical Success:

• Clinical success rates were similar between the two groups.

3. Adverse Events:

• Both procedures had comparable adverse event profiles, indicating similar levels of safety.

4. Overall Survival:

• No significant difference in overall survival was observed between the two groups.

Conclusion:

The study concluded that EUS-GBD is a viable and effective alternative to EUS-CDS as a first-line therapy for distal malignant biliary obstruction. Both approaches demonstrated high technical and clinical success rates, comparable safety profiles, and similar survival outcomes. This suggests that the choice between EUS-GBD and EUS-CDS can be guided by factors such as anatomical considerations, operator expertise, and patient-specific characteristics.

Implications:

This trial supports the use of EUS-guided procedures as effective alternatives to ERCP in managing distal MBO. The findings reinforce the flexibility in choosing between EUS-GBD and EUS-CDS, allowing clinicians to tailor their approach to the individual needs of the patient.