title: Endoscopic Ultrasound-Guided Biliary Drainage: A Systematic Review and Meta-Analysis.
abstract: OBJECTIVE
  Variable success and adverse event rates have been reported for endoscopic ultrasound-guided biliary drainage (EUS-BD) utilizing either extrahepatic or intrahepatic approach. We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of EUS-BD and to compare the two approaches and transluminal methods of EUS-BD.
  
  
  METHODS
  We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ISI Web of Science, and Scopus from January 2001 through January 5, 2015, to identify studies reporting technical success and adverse events of EUS-BD. A sample size of more than 20 patients was a further criterion. Weighted pooled rate (WPR) for technical success and post-procedure complications was calculated for overall studies and predefined subgroups. Pooled odds ratios were calculated for technical success and adverse events for two approaches and transluminal methods of EUS-BD for distal common bile duct (CBD) strictures.
  
  
  RESULTS
  The WPR with 95% confidence interval (CI) for technical success and post-procedure adverse events was 90% (86, 93%) and 17% (13, 22%), respectively, with considerable heterogeneity (I(2) = 77%). For high-quality studies, the WPR for technical success was 94% (91, 96 %), I(2) = 0% and WPR for post-procedure adverse event was 16% (12, 19%), I(2) = 39%. In meta-regression model, distal CBD stricture and transpapillary drainage were associated with higher technical success and intrahepatic access route was associated with higher adverse event rate. There was no difference in technical success using either approach OR 1.27 (0.52, 3.13), I(2) = 0% or transluminal method OR 1.32 (0.51, 3.38), I(2) = 0%. However, the extrahepatic approach appeared significantly safer as compared to the intrahepatic approach OR 0.35 (0.19, 0.67), I(2) = 27%. Likewise, choledochoduodenostomy was found to have less adverse events as compared to hepaticogastrostomy, OR 0.40 (0.18, 0.87), I (2) = 0%.
  
  
  CONCLUSIONS
  In cases of failure of traditional ERC to achieve biliary drainage, EUS-BD appears to be an emerging therapeutic modality with a cumulative success rate of 90% and cumulative adverse events rate of 17%. Randomized controlled trials are required to further evaluate the efficacy and safety of the procedure along with the comparison to traditional modalities like percutaneous transhepatic biliary drainage.
authors.affiliation: Division of Gastroenterology, University of Tennessee Health Science Center, 956 Court Avenue, Suite H210, Memphis, TN, 38163, USA. mkhan24@uthsc.edu.
authors.forename: Muhammad Ali
authors.initials: MA
authors.lastname: Khan
authors.affiliation: Division of Gastroenterology, University of Tennessee Health Science Center, 956 Court Avenue, Suite H210, Memphis, TN, 38163, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Akbar
authors.affiliation: Division of Gastroenterology, University of North Carolina, Chapel Hill, NC, USA.
authors.forename: Todd H
authors.initials: TH
authors.lastname: Baron
authors.affiliation: Division of Gastroenterology, University of Toledo, Toledo, OH, USA.
authors.forename: Sobia
authors.initials: S
authors.lastname: Khan
authors.affiliation: Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Mehmat
authors.initials: M
authors.lastname: Kocak
authors.affiliation: Division of Gastroenterology, University of Toledo, Toledo, OH, USA.
authors.forename: Yaseen
authors.initials: Y
authors.lastname: Alastal
authors.affiliation: Division of Gastroenterology, University of Toledo, Toledo, OH, USA.
authors.forename: Tariq
authors.initials: T
authors.lastname: Hammad
authors.affiliation: Carlson and Mulford Libraries, University of Toledo, Toledo, OH, USA.
authors.forename: Wade M
authors.initials: WM
authors.lastname: Lee
authors.affiliation: Division of Gastroenterology, University of Toledo, Toledo, OH, USA.
authors.forename: Aijaz
authors.initials: A
authors.lastname: Sofi
authors.affiliation: Division of Gastroenterology, University of Sao Paulo, São Paulo, Brazil.
authors.forename: Everson L A
authors.initials: EL
authors.lastname: Artifon
authors.affiliation: Division of Gastroenterology, University of Toledo, Toledo, OH, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Nawras
authors.affiliation: Division of Gastroenterology, University of Tennessee Health Science Center, 956 Court Avenue, Suite H210, Memphis, TN, 38163, USA. mismail@uthsc.edu.
authors.forename: Mohammad Kashif
authors.initials: MK
authors.lastname: Ismail
mesh_terms: D001652:Bile Ducts / Q000601:surgery; D002768:Choledochostomy / Q000379:methods*; D002779:Cholestasis / Q000601:surgery*; D003135:Common Bile Duct / Q000601:surgery*; D004322:Drainage / Q000379:methods; D019160:Endosonography / Q000379:methods; D006801:Humans; D025321:Surgery, Computer-Assisted / Q000379:methods
keywords: Antegrade biliary drainage; Choledochoduodenostomy; EUS-BD; Hepaticogastrostomy; Rendezvous