Endoscopic ultrasound (EUS)-guided biliary drainage is an alternative technique for biliary decompression when ERCP fails. This study aims to compare the efficacy, safety, and clinical outcomes of EUS-guided biliary drainage versus ERCP in patients with distal malignant biliary obstructions (MBO).

A single-center retrospective study was conducted on patients undergoing biliary drainage for MBO via EUS or ERCP between 2018 and 2024. Outcomes included technical success, clinical success (symptom resolution or bilirubin reduction ≥50% at 14 days/≥75% at 28 days), adverse events (AEs), reintervention rates, and long-term outcomes (survival, oncology treatment access). Continuous variables were compared using the Student’s t-test, while categorical variables were analyzed using the Chi-square or Fisher’s exact test. Survival rates were estimated using the Kaplan-Meier method. A p-value <0.05 was considered statistically significant.

A total of 84 patients were enrolled in the study (31 EUS-group and 53 ERCP-group), with a combined total of 93 procedures (34 EUS and 59 ERCP). Technical success was achieved in 100% of EUS-BD and 94.9% of ERCP cases (p=0.181), with clinical success rates of 92.9% and 94.1%, respectively (p=0.816). No significant differences were found in total hospital stay (7.3 vs 6.6 days, p=0.484) or post-procedural stay (4.6 vs 3.4 days, p=0.094). Peri-procedural adverse events occurred in 11.8% (EUS) vs 5.1% (ERCP) (p=0.207), while post-procedural complications were recorded in 5.9% vs 11.9% (p=0.642). Regarding long-term outcomes, mortality during follow-up was significantly lower in the EUS group (64.5% vs 73.6%, p=0.008), although mean survival time did not differ significantly (189 vs 285 days, p=0.205). Access to chemotherapy was similar between groups (39.1% vs 55.8%, p=0.196).

Both methods proved effective, with a slight but not statistically significant advantage for EUS-BD in technical success and for ERCP in clinical success. Both EUS-BD and ERCP are effective options for biliary drainage in patients with malignant biliary obstructions. The choice of procedure may depend on the patient's clinical profile and the availability of experienced operators, considering individual characteristics and the specific risks associated with each technique.