ERCP is the established method for biliary drainage in patients with malignant distal biliary obstruction (MDBO); however, in approximately 5-15% of cases ERCP may fail.Various salvage techniques are used to effectively drain the biliary tract in patients with MDBO, including percutaneous transhepatic cholangiography (PTC), EUS-guided choledochoduodenostomy (EUS-CDS) and EUS-guided rendezvous technique (EUS-RV). The aim of this study is to compare the clinical efficacy and safety of PTC, EUS-CD and EUS-RV in patients with MDBO and failed ERCP drainage.

Data from patients with MDBO who underwent PTC, EUS-CDS or EUS-RV (1/2022-8/2024) after failed ERCP were retrospectively studied. MDBO was defined as malignant obstruction between the papilla and the cystic duct. All patients had previously failed ERCP drainage, either because it was not technically feasible or because it did not reduce bilirubin levels. The primary endpoint was the clinical success of the method (reduction in total bilirubin of at least 50% at 2 weeks). The secondary endpoint was the occurrence of complications.

A total of 66 patients (45,9% males) were included, categorized by underlying pathology: distal cholangiocarcinoma (24 patients, 36,4%), periampullary carcinoma (23 patients, 34,8%), and pancreatic carcinoma (19 patients, 28,8%). Intervention types included EUS-CDS drainage (30 patients, 45,5%), PTC (13 patients, 34,8%), and EUS-rendezvous technique (23 patients, 34,8%). Mean initial total bilirubin was 10.6 ± 4.7 mg/dL, decreasing to 3.1 ± 3.4 mg/dL post-intervention, representing a mean reduction of 69.6%.  The clinical success rate of EUS-CDS (90%) was significantly higher as compared , with the most common complications being bleeding (6.7%) and peritonitis (3.3%). Regarding clinical success, EUS-CDS showed a statistical trend toward higher clinical success compared to PTBD (90% vs 69.2%, p= 0,09), although no significant difference was detected in comparison with EUS-RV (90% vs 78.3%, p = 0.237). PTC showed a success rate of 69.2% with the most common complications being abscess formation (15.4%), biloma (7.7%) and cholangitis (7.7%). The EUS-RV technique was clinically successful in 78.3%, with the most frequent complication being bleeding (17.4%) followed by cholangitis (4.3%). 

Pairwise comparisons of complication distributions showed a borderline significant difference between EUS-CDS and EUS-RV technique (p≈0.04–0.05), with higher bleeding in the rendezvous group. Comparisons between EUS-CDS vs PTC and PTC vs EUS-RV did not reach statistical significance (p>0.05), although PTC tended to have more infectious complications and abscess, while EUS-RV technique had more bleeding.

All complications were treated conservatively and no patient died due to complications.

EUS-guided biliary drainage demonstrates superior clinical success rates and lower complication rates compared to PTC and EUS-RV technique in patients with failed ERCP for MDBO. These findings support EUS-guided intervention as the preferred alternative drainage method when ERCP is unsuccessful.