Endoscopic Ultrasound-Guided Biliary Drainage: A Systematic Review and Meta-Analysis

Abstract

Background and Aims

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 %.

Conclusion

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.

Appendices

Appendix 1

See Fig. 11.

Fig. 11

Quality assessment tables

Appendix 2

See Fig. 12.

Fig. 12

Funnel plot for technical success of EUS-BD

Appendix 3

See Fig. 13.

Fig. 13

Funnel plot for clinical success of EUS-BD

Appendix 4

See Fig. 14.

Fig. 14

Funnel plot for post-procedure adverse event rates of EUS-BD

Appendix 5

See Fig. 15.

Fig. 15

Funnel plot for comparing the technical success of extrahepatic versus intrahepatic approach in distal biliary strictures

Appendix 6

See Fig. 16.

Fig. 16

Funnel plot for comparing the post-procedure adverse event rates of extrahepatic versus intrahepatic approach in distal biliary strictures

Appendix 7

See Fig. 17.

Fig. 17

Funnel plot for comparing technical success of choledochoduodenostomy versus hepaticogastrostomy in distal biliary strictures

Appendix 8

See Fig. 18.

Fig. 18

Funnel plot for comparing the post-procedure adverse events with choledochoduodenostomy versus hepaticogastrostomy in distal biliary strictures