title: Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis.
abstract: OBJECTIVE
  EUS-guided biliary drainage (EUS-BD) is increasingly used as an alternate therapeutic modality to percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction in patients who fail ERCP. We conducted a systematic review and meta-analysis to compare the efficacy and safety of these 2 procedures.
  
  
  METHODS
  We searched several databases from inception to September 4, 2016 to identify comparative studies evaluating the efficacy and safety of EUS-BD and PTBD. Primary outcomes of interest were the differences in technical success and postprocedure adverse events. Secondary outcomes of interest included clinical success, rate of reintervention, length of hospital stay, and cost comparison for these 2 procedures. Odds ratios (ORs) and standard mean difference were calculated for categorical and continuous variables, respectively. These were analyzed using random effects model of meta-analysis.
  
  
  RESULTS
  Nine studies with 483 patients were included in the final analysis. There was no difference in technical success between 2 procedures (OR, 1.78; 95% CI, .69-4.59; I2= 22%) but EUS-BD was associated with better clinical success (OR, .45; 95% CI, .23-.89; I2= 0%), fewer postprocedure adverse events (OR, .23; 95% CI, .12-.47; I2= 57%), and lower rate of reintervention (OR, .13; 95% CI, .07-.24; I2= 0%). There was no difference in length of hospital stay after the procedures, with a pooled standard mean difference of -.48 (95% CI, -1.13 to .16), but EUS-BD was more cost-effective, with a pooled standard mean difference of -.63 (95% CI, -1.06 to -.20). However, the latter 2 analyses were limited by considerable heterogeneity.
  
  
  CONCLUSIONS
  When ERCP fails to achieve biliary drainage, EUS-guided interventions may be preferred over PTBD if adequate advanced endoscopy expertise and logistics are available. EUS-BD is associated with significantly better clinical success, lower rate of postprocedure adverse events, and fewer reinterventions.
authors.affiliation: Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Reem Z
authors.initials: RZ
authors.lastname: Sharaiha
authors.affiliation: Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
authors.forename: Muhammad Ali
authors.initials: MA
authors.lastname: Khan
authors.affiliation: Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
authors.forename: Faisal
authors.initials: F
authors.lastname: Kamal
authors.affiliation: Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Amy
authors.initials: A
authors.lastname: Tyberg
authors.affiliation: Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
authors.forename: Claudio R
authors.initials: CR
authors.lastname: Tombazzi
authors.affiliation: Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
authors.forename: Bilal
authors.initials: B
authors.lastname: Ali
authors.affiliation: Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
authors.forename: Claudio
authors.initials: C
authors.lastname: Tombazzi
authors.affiliation: Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Michel
authors.initials: M
authors.lastname: Kahaleh
mesh_terms: D001662:Biliary Tract Surgical Procedures / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002779:Cholestasis / Q000601:surgery*; D004322:Drainage / Q000379:methods*; D019160:Endosonography; D006801:Humans; D025321:Surgery, Computer-Assisted / Q000379:methods*; D017211:Treatment Failure; D016896:Treatment Outcome