Advanced cannulation techniques vs early EUS-BD in case of difficult biliary cannulation in patients with DMBO: an international propensity score-matched analysis
Marco Spadaccini, Jérémie Albouys, Cecilia Binda, Aurelio Mauro, Arnaldo Amato, Michele Amata, Filippo Antonini, José Ramón Aparicio Tormo, Paolo Giorgio Arcidiacono, Giovanni Aragona, Alexander Arlt, Debora Berretti, Torsten Beyna, Ivo Boskoski, Lucio Carrozza, Natalia Causada Calo, Anna Cominardi, Giuseppe Dell’Anna, Giovanna Del Vecchio Blanco, Roberto Di Mitri, Gianfranco Donatelli, Francesco Ferrara, Alessandro Fugazza, Pietro Fusaroli, Joan B. Gornals, Mateusz Jagielski, Kareem Khalaf, Romain Legreos, Andrea Lisotti, Giovanni Lombardi, Ludovic Lukenga Safu, Alberto Martino, Belen Martínez-Moreno, Tajana Pavic, Enrique Perez-Cuadrado Robles, Ulrich Rosien, Valeria Poletti, Abdulrahman Qatomah, Daryl Ramai, Gianenrico Rizzatti, Giacomo Emanuele Maria Rizzo, Andrada Seicean, Cristiano Spada, Albert Sumalla-Garcia, Ilaria Tarantino, Maria Terrin, Viveksandeep Thoguluva Chandrasekar, Edoardo Troncone, Giuseppe Vanella, Thomas Veiser, Katina Zheng, Cesare Hassan, Carlo Fabbri, Andrea Anderloni, Jeremie Jacques, Alessandro Repici,Background and objectives:
Biliary drainage(BD)in distal malignant biliary obstruction(DMBO)is often hampered by difficult biliary cannulation(DBC)during endoscopic retrograde cholangiopancreatography(ERCP). Advanced cannulation techniques(aERCP)may overcome DBC but still fail in up to 15% of cases, increasing the risk of adverse events(AEs). Early endoscopic ultrasound-guided BD(eEUS-BD)is a potential alternative. The aim of this study is to directly compare safety and efficacy of EUS-BD and aERCP.
Methods:
This is a retrospective, multicentric study(29 centres in United States, Canada, Europe), including patients with DMBO and common bile duct(CBD)diameter >12 mm, treated up to 2024. DBC cases managed with either eEUS-BD or aERCP were analysed. A 1:2 propensity score-matched cohort was generated to ensure comparability, with regression modeling and inverse probability of treatment weighting(IPTW)performed as sensitivity analyses. AEs rate was the primary outcome; secondary outcomes included BD failure and clinical success.
Results:
Standard cannulation failed in 2066/10,738(19.2%)ERCPs. aERCP and eEUS-BD were attempted in 1733 and 333 cases, respectively. After matching, 313 patients per EUS-BD group and 626 patients per aERCP group were analyzed. AEs occurred in 18.2% of aERCPs and 9.3% of eEUS-BD(p<0.01), with post-procedural pancreatitis the most frequent AE after aERCP(55 cases, 12.0%). Both regression and IPTW confirmed the robustness of these findings on the entire cohort. Technical success was significantly lower with aERCP(82.0% vs. 95.9%, p<0.01), clinical success was comparable(94.5% vs. 96.4%, p=0.89).
Conclusions:
In patients with DMBO and dilated CBD, eEUS-BD is associated with fewer AEs and higher technical success than aERCP, supporting its role as a safer, more effective option in DBC.