Endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) has emerged as an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage in patients with malignant distal biliary obstruction (MDBO). With cautery-enhanced lumen-apposing metal stents (CE-LAMS), EUS-CDS has become more feasible, yet concerns remain regarding stent patency and safety. Comparative data between CE-LAMS–based and conventional self-expandable metal stents (SEMS)-based EUS-CDS are lacking.

A systematic review and network meta-analysis was conducted including randomized controlled trials (RCTs) comparing EUS-CDS using CE-LAMS or SEMS with ERCP in MDBO.Procedural outcomes were technical success defined as the rate of accurate placement of either LAMS, or SEMS within the CBD, with bile flowing through the stent, and mean procedure time, defined as the time (in minute) to reach the technical success. Clinical outcomes were clinical success defined as the pooled rate of patients with a ≥50% reduction in serum bilirubin to <3 mg/dL within two weeks (and clinical improvement in case of concomitant cholangitis), and overall adverse events. Pooled rate of cholangitis, was also assessed, it was defined and classified per the American Society for Gastrointestinal Endoscopy lexicon. Pairwise and network meta-analyses were performed using random-effects models. Ranking probabilities were assessed using the surface under the cumulative ranking curve (SUCRA).

Six randomized controlled trials, comprising 707 patients, were included in the analysis.

EUS-CDS with EC-LAMS significantly outperformed both EUS-CDS with SEMS (RR: 1.22; 95% CI: 1.10 to 1.36) and ERCP (RR: 1.18; 95% CI: 1.10 to 1.27) in achieving technical success. No significant difference was observed between EUS-CDS with SEMS and ERCP in either the direct (RR: 0.97; 95% CI: 0.89 to 1.05) or the indirect comparison (RR: 0.97; 95% CI: 0.89 to 1.05). SUCRA analysis identified EUS-CDS with EC-LAMS as the best-performing approach (SUCRA = 1.00), while EUS-CDS with SEMS ranked lowest (SUCRA = 0.12). In terms of procedure time, EUS-CDS with EC-LAMS demonstrated a significantly shorter duration compared to both EUS-CDS with SEMS (SMD: –0.78; 95% CI: –1.30 to –0.27) and ERCP (SMD: –0.84; 95% CI: –1.16 to –0.52). No significant difference in procedure time was found between EUS-CDS with SEMS and ERCP in either the direct (SMD: –0.05; 95% CI: –0.35 to 0.46) or the indirect comparison (SMD: –0.05; 95% CI: –0.35 to 0.46). SUCRA rankings again favored EUS-CDS with EC-LAMS as the most effective strategy (SUCRA = 1.00), while EUS-CDS with SEMS and ERCP ranked equally as the least favorable options (SUCRA = 0.25).On network meta-analysis, no difference was observed among the different techniques of performing EUS-CDS in terms of clinical success as compared to ERCP or compared to each other.SUCRA analysis  identified EUS-CDS with EC-LAMS as the best-performing approach (SUCRA = 0.68), while EUS-CDS with SEMS ranked lowest (SUCRA = 0.27).When focusing on safety, in the network meta-analysis, no significant differences in adverse event rates were observed among the various techniques of EUS-CDS compared to ERCP, nor among the EUS-CDS techniques themselves  According to SUCRA analysis, EUS-CDS with SEMS was identified as the safest approach (SUCRA = 0.85), while ERCP ranked lowest (SUCRA = 0.29)When specifically assessing the incidence of cholangitis, no significant differences were found among the different biliary drainage strategies

EUS-CDS with CE-LAMS offers superior procedural efficiency compared to ERCP and SEMS-based approaches with similar clinical success and safety, though concerns about cholangitis warrant further evaluation.