Summary
A medRxiv systematic review and meta-analysis of three randomized controlled trials involving 519 patients found that EUS-guided choledochoduodenostomy with a lumen-apposing metal stent had higher technical success than ERCP with a self-expandable metal stent for malignant distal biliary obstruction. Procedure time and postprocedural pancreatitis risk were also lower, while clinical success and overall adverse events were comparable.
A systematic review and meta-analysis posted as a medRxiv preprint found that endoscopic ultrasound-guided choledochoduodenostomy using a lumen-apposing metal stent was associated with higher technical success than ERCP using a self-expandable metal stent for malignant distal biliary obstruction. The analysis included three randomized controlled trials and 519 patients.
The authors reported moderate-certainty evidence for the main comparison. The EUS-guided approach also had a shorter procedure time and a lower risk of postprocedural pancreatitis, while clinical success and overall adverse events were comparable between the approaches.
Results from three randomized trials
The researchers searched CENTRAL, PubMed and Embase through September 11, 2026, and assessed the evidence using GRADE and trial sequential analysis. The three included trials were described as high quality and compared the two procedures as primary biliary drainage strategies.
For technical success, EUS-guided drainage with a lumen-apposing metal stent had a relative risk of 1.18 compared with ERCP, with a 95% confidence interval from 1.09 to 1.28 and P < 0.0001. In relative terms, this corresponds to an estimated 18% higher likelihood of completing the intended drainage procedure with the EUS-guided approach in the pooled analysis.
The analysis also found a shorter procedure time for EUS-guided choledochoduodenostomy, with P < 0.00001, and a lower risk of pancreatitis after the procedure, with P = 0.01. The abstract does not provide absolute event rates for those outcomes. Clinical success, which concerns the intended clinical result of drainage, and overall adverse events were comparable between the groups.
Sensitivity analysis, cumulative meta-analysis and trial sequential analysis supported the main findings reported by the authors.
How the two drainage approaches differ
Malignant distal biliary obstruction is a cancer-related narrowing in the lower bile duct that can interfere with the normal passage of bile. Primary biliary drainage places a stent or creates a drainage route to restore that flow.
ERCP reaches the bile duct through the duodenum and places a self-expandable metal stent across the obstruction. In EUS-guided choledochoduodenostomy, ultrasound imaging is used to guide access from the duodenum to the bile duct, followed by placement of a lumen-apposing metal stent. The two methods therefore use different routes to achieve biliary drainage.
The distinction between technical and clinical success is important in interpreting the findings. Technical success concerns completion of the planned intervention, whereas clinical success concerns whether the drainage achieves its intended clinical effect. In this pooled analysis, the measurable advantage was seen in technical success, procedure time and postprocedural pancreatitis risk; the clinical-success and overall-adverse-event results were comparable.
The authors conclude that EUS-guided choledochoduodenostomy with a lumen-apposing metal stent may be considered an alternative primary biliary drainage option for malignant distal biliary obstruction. The report is a preprint posted on medRxiv on September 15, 2026, so its synthesis is preliminary. Its evidence base consists of three randomized trials involving 519 patients, and the abstract does not provide the absolute rates needed to judge the size of each reported benefit.