In case of suspicious malignant distal biliary obstruction the most common clinical presentation is jaundice so that pathological confirmation of malignancy and biliary drainage for symptoms palliation are required. Endoscopic ultrasound (EUS) represents the preferred diagnostic technique while endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for drainage. Tissue acquisition can be obtained by means of fine-needle aspiration (FNA) or biopsy (FNB), brushing and/or bile aspiration cytology. The simultaneous EUS and ERCP approach may offer a diagnostic and therapeutic solution using a single sedation/anesthesia, reducing hospital stay, offering a rapid relief of symptoms (jaundice, cholangitis) and a early tissue diagnosis leading to faster oncological planning. Aim of this study is to explore in a real-world setting feasibility and diagnostic effectiveness of EUS-ERCP approach for highly suspicious pancreatobiliary malignancies, valuing the individual role of different tissue acquisition techniques.

All patients underwent to EUS and ERCP in the same-session in our Endoscopic Department for jaundice in suspicious malignant distal biliary stricture between December 2023 and June 2025 were considered for retrospective analysis. Patients' and procedure characteristics were abstracted. Diagnostic accuracy of each individual techniques and of their combination were analysed.

44 patients resulted eligible (26 M, 18 F, Median age 67.7 IQR 62.8-77.4). Final diagnosis was pancreatic adenocarcinoma in 42/44 cases (95.5%) and cholangiocarcinoma in 2/44 cases (4.5%). FNB was carried out in 43/44 (97.7%), brushing in 43/44(97.7%) and bile aspiration cytology in 30/44 cases (68,2%). FNB, performed with the help of macroscopic on site evaluation (MOSE) by the endoscopist, achieved an accuracy of 90.7%, with sensitivity and specificity respectively 90.48% and 100%. Brushing and bile cytology achieved an accuracy, respectively, of 68.18% and 70%. Combining all the diagnostic techniques it was obtained a high accuracy (93.33%, 95%CI 81.73%-98.60%) with sensitivity 93,18%, specificity 100% and negative likelihood ratio 0.07 (95%CI 0.02-0.20). In 3/44 (6.8%) cases none of these techniques was diagnostic for inadequate samples, requiring a subsequent procedure (EUS in all cases), with success. Simultaneous endoscopic drainage was performed in all cases with ERCP and placement of plastic or self-expandable metal stents. Previous EUS-FNB did not impaired technical success of biliary cannulation. Median time to chemotherapy or to surgery was 27.8 days (IQR, 15-55). No major adverse events occurred, only in 1 case post-ERCP pancreatitis delayed the start of chemotherapy.

Same session EUS-guided and ERCP-guided tissue sampling with biliary drainage for symptoms palliation in real world is feasible and safe in case of distal malignant biliary obstruction. It contributes to reduce hospitalization and access time to oncological therapies and should be considered as a standard of clinical practice. In the context of neoplasms with a high cancer-related mortality, combination of sampling techniques may increase significantly diagnostic yields, reducing the need of further procedures (which cause a delay in starting treatments) and, in fact, having a positive impact on disease-specific survival.