Difficult biliary cannulation (DBC) remains a significant challenge in endoscopic retrograde cholangiopancreatography (ERCP)¹. When cannulation fails, precut techniques are widely used as rescue techniques. Endoscopic ultrasound-guided rendezvous (EUS-RV) is increasingly used by experts as an alternative to precut for cannulating the bile duct. However, there is limited literature comparing these two techniques. This systematic review and meta-analysis aimed to compare the efficacy and safety of EUS-RV versus precut techniques for biliary access in DBC. 

A systematic search was conducted across PubMed, Embase, and Cochrane Library databases up to April 2025. Studies comparing EUS-RV and precut techniques in adult patients with DBC were included. Data were pooled using a random-effects model. Primary outcome was technical success rates; secondary outcome was adverse event rates. A P value < 0.05 was considered statistically significant.

Five studies (two randomized controlled trials and three retrospective cohorts) comprising 875 patients were included. Pooled technical success was higher with EUS-RV compared with precut (95.9% vs. 91.4%; OR 2.77; 95% CI, 1.39–5.54; P = 0.004). Adverse event rates were 7.7% for EUS-RV and 11.2% for precut, with no statistically significant difference (OR 0.75; 95% CI, 0.42–1.33; P = 0.321). 

EUS-RV is associated with higher technical success compared with precut techniques for rescue biliary cannulation after failed standard ERCP, with a comparable safety profile. These findings support EUS-RV may become the preferred rescue strategy, in specific settings, when expertise is available; however, further trials are needed to assess its safety, procedural duration, and learning curve.