Methods for Drainage of Distal Malignant Biliary Obstruction after ERCP Failure: A Systematic Review and Network Meta-Analysis

SIMPLE SUMMARY: With the widespread use of EUS-guided procedures, several methods are available in order to achieve biliary drainage when endoscopic retrograde cholangiopancreatography (ERCP) fails. Together with the well established role of percutaneous trans-hepatic biliary drainage (PTBD) and surgical hepaticojejunostomy, EUS-choledochoduodenostomy (EUS-CD) and EUS-hepaticogastrostomy (EUS-HG) have provided good results to date, representing valuable alternatives. However, no definite indications have been provided about which should be the best way of drainage. In this network meta-analysis, we compared all these techniques, showing how, considering the available studies, none of these methods seems to be superior to another, although PTBD seems to have a slightly higher rate of adverse events. So, when dealing with patients affected by distal malignant biliary obstruction (DMBO) and when ERCP fails, all these methods seem to be equally effective, although possibly EUS-guided approaches could be less invasive and affected by fewer adverse events. ABSTRACT: There is scarce evidence on the comparison between different methods for the drainage of distal malignant biliary obstruction (DMBO) after endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we performed a network meta-analysis to compare the outcomes of these techniques. We searched main databases through September 2021 and identified five randomized controlled trials. The primary outcome was clinical success. The secondary outcomes were technical success, overall and serious adverse event rate. Percutaneous trans-hepatic biliary drainage was found to be inferior to other interventions (PTBD: RR 1.01, 0.88–1.17 with EUS-choledochoduodenostomy (EUS-CD); RR 1.03, 0.86–1.22 with EUS-hepaticogastrostomy (EUS-HG); RR 1.42, 0.90–2.24 with surgical hepaticojejunostomy). The comparison between EUS-HG and EUS-CD was not significant (RR 1.01, 0.87–1.17). Surgery was not superior to other interventions (RR 1.40, 0.91–2.13 with EUS-CD and RR 1.38, 0.88–2.16 with EUS-HG). No difference in any of the comparisons concerning adverse event rate was detected, although PTBD showed a slightly poorer performance on ranking analysis (SUCRA score 0.13). In conclusion, all interventions seem to be effective for the drainage of DMBO, although PTBD showed a trend towards higher rates of adverse events.