Primary drainage of distal malignant biliary obstruction: A comparative network meta-analysis

Background: The effectiveness of various primary upfront drainage techniques for distal malignant biliary obstructions (dMBO) is not well-established. Objective: To compare the technical and clinical success rates and adverse event (AE) rates of various primary drainage techniques. Methods: We systematically reviewed RCTs comparing the technical and clinical success and AE rates of EUS-choledochoduodenostomy (CDS) with lumen-apposing metal stent (LAMS), EUS-CDS with selfexpandable metal stents (SEMS), EUS-hepaticogastrostomy (HGS), ERCP, and PTBD performed upfront. Results: Six RCTs involving 583 patients were analyzed. EUS-CDS with LAMS showed significantly higher technical success compared to EUS-CDS with SEMS (RR 1.21, 95 % CI 1.07-1.37) and ERCP (RR 1.17, 95 % CI 1.07-1.28). EUS-CDS with LAMS had the highest rank in technical success (SUCRA = 0.86). The clinical success rate was also higher with EUS-CDS with LAMS than with ERCP (RR 1.12, 1.01-1.25). PTBD was the worst ranked procedure for safety (SUCRA score = 0.18), while EUS-CDS with LAMS was the top procedure for procedural time (SUCRA score = 0.83). Conclusion: EUS-CDS with LAMS has the highest technical and clinical success rates and is significantly superior to ERCP as the upfront technique for dMBO treatment. PTBD should be abandoned as first-line treatment due to the poor safety profile. (c) 2024 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.