To compare technical success, clinical success, bilirubin response, safety, and survival between EUS-BD and PTBD after failed ERCP in patients with malignant biliary obstruction treated at a Brazilian tertiary referral center.

Retrospective cohort study including 67 consecutive oncology patients (34 EUS-BD, 33 PTBD) managed between 2013 and 2023 after unsuccessful ERCP. All EUS-BD procedures were performed with lumen-apposing metal stents (LAMS) or self-expandable metal stents via hepaticogastrostomy or choledochoduodenostomy routes. Demographic, laboratory, procedural and follow-up data were collected. Categorical variables were compared using χ² or Fisher’s exact test; continuous variables using Student’s t-test or Mann–Whitney U test. Survival was evaluated by Kaplan–Meier curves and log-rank test. A p-value <0.05 was considered significant.

Baseline characteristics were comparable except for oncological stage: stage IV disease was significantly more frequent in the EUS-BD group (p=0.004). Technical success was 100% in both arms. Clinical success (resolution of jaundice or >50% bilirubin reduction within 30 days) was similar (EUS-BD 70.6% vs PTBD 78.8%; p=0.576). Pre-procedure total and direct bilirubin levels were higher in the PTBD group (p=0.019 and p=0.011, respectively), yet both techniques achieved significant bilirubin decline.

Peri-interventional adverse events occurred in 8.8% (EUS-BD) versus 3.0% (PTBD) (p=0.614); most were mild and managed conservatively. In-hospital late adverse events (AE) were 29.4% versus 33.3% (p=0.796) and post-discharge AE 29.4% versus 18.2% (p=0.147), with no significant differences. Severity of AE according to ASGE lexicon was also comparable. Notably, despite more advanced oncological stage at baseline, the EUS-BD cohort exhibited significantly better in-hospital survival (log-rank p<0.05); overall survival did not differ between groups.

In this 10-year Latin-American oncology cohort with failed ERCP, EUS-BD provided technical and clinical success rates equivalent to PTBD, with comparable safety profiles despite treating patients with more advanced disease. EUS-BD was associated with improved in-hospital survival and avoided external catheters, enhancing patient comfort and quality of remaining life. Selection bias (physician preference) cannot be excluded. Nevertheless, our findings support EUS-BD as the preferred rescue strategy after failed ERCP in malignant biliary obstruction and underline the need for institutional protocols favouring endoscopic ultrasound-guided approaches over percutaneous routes.