EUS-guided biliary drainage achieves higher technical and clinical success rates than balloon enteroscopy-assisted ERCPEUS-Guided Drainage Shows Higher Success for Biliary Obstruction

OBJECTIVES: This systematic review and meta-analysis evaluated the pooled outcomes and comparative evidence of balloon enteroscopy-assisted ERCP (BEA-ERCP) and EUS-guided biliary drainage (EUS-BD) for malignant biliary obstruction (MBO) in patients with surgically altered anatomy (SAA). METHODS: PubMed, Web of Science, and the Cochrane Library were searched up to January 2026. The primary outcome was the pooled technical success rate. Secondary outcomes included the clinical success rate, adverse event rate, recurrent biliary obstruction (RBO) rate, and mean procedure time. Subgroup analyses compared outcomes in studies directly comparing the two procedures. A random-effects model was used. RESULTS: Thirteen studies were included, comprising nine studies investigating BEA-ERCP (394 patients) and seven investigating EUS-BD (206 patients), including three comparative studies. Pooled technical and clinical success rates were 75% and 72% for BEA-ERCP and 97% and 92% for EUS-BD, respectively. Pooled adverse event rates were 11% for BEA-ERCP and 17% for EUS-BD, and pooled RBO rates were 26% and 23%, respectively. In subgroup analyses of the three comparative studies, technical success rates (risk ratio [RR], 0.74; 95% confidence interval [CI], 0.67-0.82) and clinical success rates (RR, 0.70; 95% CI, 0.61-0.80) were significantly lower with BEA-ERCP than with EUS-BD, with no significant differences in adverse event rates, RBO rates, or procedural times. CONCLUSION: In the three comparative studies, EUS-BD achieved higher technical and clinical success rates than BEA-ERCP for MBO in patients with SAA, with no significant difference in adverse events. These non-randomized findings are preliminary, and large-scale prospective comparative studies are warranted.