Reply to Lisotti et al.

10.1055/a-2715-8374

We thank Dr. Lisotti and colleagues for their comments on our manuscript [1]. Despite numerous publications (including ours) and guideline recommendations from both the European Society of Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE), percutaneous transhepatic biliary drainage (PTBD) continues to be the initial alternative drainage modality after failed endoscopic retrograde cholangiopancreatography (ERCP). In tertiary referral centers with a focus on interventional endoscopy, this trend does not hold; however, in most hospitals around the world where interventional radiology is available, PTBD is common practice.

Given the well-recognized difficulty of altering clinical practice, we felt a responsibility to generate evidence in an ethical manner. The medical ethics committee has requested the presentation of real-world data as a prerequisite before approving further research, for example a randomized controlled trial (RCT). Our study design and the under-representation of patients undergoing PTBD compared with EUS-BD reflects our intention to provide real-world data. The majority of Dutch gastroenterologists have had negative experiences with indwelling percutaneous transhepatic biliary drains in their patients. In both tertiary academic and community hospitals, EUS-guided biliary drainage (EUS-BD) was chosen over PTBD, which resulted in fewer PTBD inclusions than we would have initially wished for.

Although the group undergoing PTBD was relatively small, the real-world practice of choosing EUS-BD over PTBD seems a correct choice. A so-called rigorous methodological trial design, preferably including randomization, would have exposed fragile patients to a 50% chance of receiving a potentially harmful bile duct intervention in the last phase of their lives.

Ideally, future research should involve a carefully designed study, from the perspective of the daily (world) standard, namely PTBD; however, such a study may not reveal the superiority of advanced techniques, but rather highlight the limitations and potential harms of the current prevailing practice.

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