Primary endoscopic ultrasound-guided choledochoduodenostomy versus endoscopic retrograde cholangiopancreatography for the drainage of distal malignant biliary obstruction: An Egyptian multicenter, prospective, comparative study

Background: Endoscopic ultrasound-guided biliary drainage is widely accepted due to its high success rate, minimal need for re-intervention, and low incidence of pancreatitis. Our objective was to investigate the feasibility, efficacy, and outcomes of primary EUS-guided choledochoduodenostomy (EUS-CDS) compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant distal biliary obstruction (MDBO). Methods: In this prospective multicenter study conducted between May 2021 and April 2023, patients with unresectable MDBO were assigned to either EUS-CDS or ERCP. Technical and clinical success were the primary endpoints. Results: A total of 73 patients at three tertiary centers were enrolled, of whom 37 underwent EUS-CDS and 36 underwent ERCP. Pancreatic cancer was present in 62 patients (84.9%). The technical and clinical success rates were comparable (97.3% and 97.2% for EUS-CDS vs. 94.4% and 100% for ERCP, respectively), with nearly the same procedure duration (P = 0.982) and with no significant difference in adverse events between both groups. Pancreatitis occurred in one patient after ERCP. Short-term re-intervention (within 3 months) was only required in two patients in the EUS-CDS group. Conclusion: Primary EUS-CDS—even in developing countries—is feasible, with comparable safety and non-inferior efficacy to ERCP for palliation in MDBO cases if a highly experienced team is present.