Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: adequately designed studies are still needed

10.1055/a-2580-1316

We read with interest the article by de Jong et al. [1], reporting the outcomes of a prospective study comparing endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with percutaneous transhepatic biliary drainage (PTBD) in patients suffering from distal malignant biliary obstruction (MBO) who had had a failed attempt at endoscopic retrograde cholangiopancreatography (ERCP) [1].

International guidelines agree in preferring EUS-guided biliary drainage (EUS-BD) over PTBD in this setting; however, while this is recommended by the European Society of Gastrointestinal Endoscopy (ESGE), the American Society for Gastrointestinal Endoscopy (ASGE) just suggest it, with the strength of recommendation (strong for ESGE, conditional for ASGE) and the evaluation of evidence (moderate quality for ESGE, low quality for ASGE) also differing [2] [3]. Both guidelines ultimately recommend further studies to address this relevant clinical question.

The study by de Jong et al. added valuable data in this respect, finding lower mortality, fewer adverse events (AEs), and shorter hospital stays with EUS-CDS than with PTBD; however, we believe that some important limitations should be acknowledged. First, only 55 patients across 15 centers over an 18-month period was a relatively small sample size. Second, the PTBD arm was under-represented with just 12 patients, which may have skewed comparisons. Third, the AE rate in the PTBD group (92% at 90 days) appeared much higher than what has been consistently reported [4]. We believe that these factors may limit the generalizability of this study’s findings.

We agree with the authors that randomized controlled trials are needed to clarify the best back-up approach after failed ERCP in patients with distal MBO [5]. Importantly, future studies should ensure adequate sample sizes, balanced allocation between groups, and a standardized approach to PTBD, given the variability in techniques and devices. Only with such rigorous methodology can we ensure that future guidelines will be based on high quality evidence.

In conclusion, we wish to congratulate the authors on their contribution and to share our plea for adequately powered trials with standardized comparators to prove the superiority of EUS-BD.

Publication History

Article published online:
15 December 2025

• References

• 1 de Jong MJP, van Delft F, van Geenen EJM. et al. Endoscopic ultrasound-guided choledochoduodenostomy results in fewer complications than percutaneous drainage following failed ERCP in malignant distal biliary obstruction. Endoscopy 2025; 57: 1004-1015
• 2 van Wanrooij RLJ, Bronswijk M, Kunda R. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2022; 54: 310-332
• 3 Pawa S, Marya NB. ASGE Standards of Practice Committee . et al. American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: summary and recommendations. Gastrointest Endosc 2024; 100: 967-979
• 4 Fairchild AH, Hohenwalter EJ. Expert Panel on Interventional Radiology. et al. ACR Appropriateness Criteria Radiologic Management of Biliary Obstruction. J Am Coll Radiol 2019; 16: S196-S213
• 5 Khoury T, Sbeit W, Fumex F. et al. Endoscopic ultrasound- versus ERCP-guided primary drainage of inoperable malignant distal biliary obstruction: systematic review and meta-analysis of randomized controlled trials. Endoscopy 2024; 56: 955-963