Primary drainage of distal malignant biliary obstruction: A comparative network meta-analysis

Background: The effectiveness of various primary upfront drainage techniques for distal malignant biliary obstructions (dMBO) is not well-established. Objective: To compare the technical and clinical success rates and adverse event (AE) rates of various primary drainage techniques. Methods: We systematically reviewed RCTs comparing the technical and clinical success and AE rates of EUS-choledochoduodenostomy (CDS) with lumen-apposing metal stent (LAMS), EUS-CDS with self-expandable metal stents (SEMS), EUS-hepaticogastrostomy (HGS), ERCP, and PTBD performed upfront. Results: Six RCTs involving 583 patients were analyzed. EUS-CDS with LAMS showed significantly higher technical success compared to EUS-CDS with SEMS (RR 1.21, 95 % CI 1.07-1.37) and ERCP (RR 1.17, 95 % CI 1.07-1.28). EUS-CDS with LAMS had the highest rank in technical success (SUCRA = 0.86). The clinical success rate was also higher with EUS-CDS with LAMS than with ERCP (RR 1.12, 1.01-1.25). PTBD was the worst ranked procedure for safety (SUCRA score = 0.18), while EUS-CDS with LAMS was the top procedure for procedural time (SUCRA score = 0.83). Conclusion: EUS-CDS with LAMS has the highest technical and clinical success rates and is significantly superior to ERCP as the upfront technique for dMBO treatment. PTBD should be abandoned as first-line treatment due to the poor safety profile.