Salman A, Salman MA, Shaaban HE. Endoscopic ultrasound-guided biliary drainage vs endoscopic retrograde cholangiopancreatography for malignant distal obstruction: Randomized-trial meta-analysis. World J Meta-Anal 2026; 14(3): 124719 [DOI: 10.13105/wjma.124719]
Corresponding Author of This Article
Ahmed Salman, MD, FRACP, FRCP, Department of Internal Medicine, Kasr Alainy School of Medicine, 1 Al-Saray Street, Al-Manial, Cairo 11562, Egypt. awea844@gmail.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
research-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Meta-Anal. Sep 18, 2026; 14(3): 124719 Published online Sep 18, 2026. doi: 10.13105/wjma.124719
Endoscopic ultrasound-guided biliary drainage vs endoscopic retrograde cholangiopancreatography for malignant distal obstruction: Randomized-trial meta-analysis
Ahmed Salman, Mohamed AbdAlla Salman, Hossam E Shaaban
Ahmed Salman, Department of Internal Medicine, Kasr Alainy School of Medicine, Cairo 11562, Egypt
Mohamed AbdAlla Salman, Department of General Surgery, Kasralainy School of Medicine, Cairo 11562, Egypt
Hossam E Shaaban, Department of Internal Medicine and Gastroenterology, National Hepatology and Tropical Medicine Research Institute, Cairo 11796, Egypt
Author contributions: Salman A designed research; Salman A, Salman MA, and Shaaban HE performed research; Salman A, Salman MA, and Shaaban HE analyzed data; Salman A wrote the paper; Salman MA and Shaaban HE critically revised the paper; and all authors approved the final manuscript.
AI contribution statement: OpenAI Codex (GPT-6.5) was used to assist with literature-search organization, language polishing, and figure preparation. The authors independently verified study eligibility, references, interpretation, and conclusions, and take full responsibility for the accuracy, originality, and integrity of the manuscript.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Check-list.
Corresponding author: Ahmed Salman, MD, FRACP, FRCP, Department of Internal Medicine, Kasr Alainy School of Medicine, 1 Al-Saray Street, Al-Manial, Cairo 11562, Egypt. awea844@gmail.com
Received: June 23, 2026 Revised: August 13, 2026 Accepted: September 1, 2026 Published online: September 18, 2026 Processing time: 80 Days and 23.8 Hours
Abstract
BACKGROUND
Randomized trials have compared primary transmural endoscopic ultrasound-guided biliary drainage with endoscopic retrograde cholangiopancreatography. However, differences in devices, expertise, patient selection, and outcome definitions limit broad conclusions.
AIM
To compare the efficacy and safety of primary ultrasound-guided vs retrograde biliary drainage.
METHODS
PubMed, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization registry records indexed using CENTRAL were searched on August 6, 2026, without language restrictions. We included randomized trials comparing primary transmural ultrasound-guided vs retrograde drainage for malignant distal biliary obstruction. Risk ratios were calculated using Paule-Mandel random effects and modified Hartung-Knapp confidence intervals. Pancreatitis was examined using continuity-corrected risk ratio, Peto odds ratio, exact odds ratio, and absolute risk difference.
RESULTS
The six trials included 739 participants. Technical success did not differ significantly (risk ratio 1.08, 95% confidence interval 0.96-1.22; I2 = 64%), and clinical success was comparable (risk ratio 1.01, 95% confidence interval 0.95-1.07; I2 = 0%). Procedure-related adverse events were similar (risk ratio 0.83, 95% confidence interval 0.53-1.31). Pancreatitis occurred in 2/374 (0.5%) vs 24/365 (6.6%) participants (risk ratio 0.20, 95% confidence interval 0.05-0.77; Peto odds ratio 0.17, 95% confidence interval 0.08-0.36). The absolute risk difference was -6.0%, corresponding to a number needed to treat of 17. Stent dysfunction or re-intervention was numerically less frequent, with its confidence interval including no effect.
CONCLUSION
Ultrasound-guided drainage reduces pancreatitis and is a reasonable alternative for selected patients in expert centers; however, it is not a universal replacement for retrograde drainage.
Core Tip: This randomized meta-analysis included six trials and 739 participants. Primary transmural ultrasound-guided and retrograde biliary drainage achieved comparable clinical success rates. Ultrasound-guided drainage reduced post-procedural pancreatitis from 6.6% to 0.5%, with concordant rare-event sensitivity analyses. Technical success varies across devices and trials, whereas its effects on other adverse events and repeat interventions remain uncertain. Evidence supports ultrasound-guided drainage as an alternative for selected patients in expert centers, and not as a universal replacement for retrograde drainage.
