Endoscopic Ultrasound-Guided Biliary Drainage in Altered Gastrointestinal Anatomy: A Systematic Review and Meta-Analysis

ERCP intubation is often difficult in patients with biliary obstruction and changes in gastrointestinal structure, such as after Roux-en-Y or Billroth II surgery. EUS-BD is an alternative method. This meta-analysis should systematically compare the efficacy and safety of EUS-BD and ERCP in these patients. Studies were retrieved from PubMed, Embase, Web of Science, and the Cochrane Library from 2011 to 2026. Original studies comparing EUS-BD and ERCP in patients with biliary obstruction who have a history of gastrointestinal reconstruction surgery were included. Two researchers independently carried out literature screening, data extraction, and quality evaluation. A meta-analysis was conducted using Review Manager. The main outcome measures are technical success rate, clinical success rate, adverse events, and procedure time. A total of 6 studies involving 572 patients (201 in the EUS-BD group and 371 in the ERCP group) were included in the technical success analysis. The meta-analysis demonstrated that the pooled technical success rate was 90.5% (182/201) for the EUS-BD group and 70.4% (261/371) for the ERCP group, yielding an odds ratio (OR) of 3.60 (95% CI: 2.12–6.13; P < 0.00001). For clinical success, the pooled odds ratio was 3.52 (95% CI: 2.07–5.98; P < 0.00001), demonstrating a statistically significant advantage over ERCP. In terms of safety, there was no difference in the overall incidence of adverse events between the two groups (25.9% vs. 20.5%; OR: 1.54, 95% CI: 0.97–2.44). In patients with biliary obstruction and surgically altered gastrointestinal anatomy, EUS-BD was associated with higher pooled technical and clinical success in the available observational studies, alongside a shorter procedure time compared to ERCP. However, current evidence remains insufficient to establish a definitive difference in overall adverse events. EUS-BD represents a viable and highly effective alternative drainage modality for this challenging population, particularly when standard ERCP is anticipated to be technically demanding. However, given the reliance on observational data, the small number of included studies, and substantial heterogeneity, these findings must be interpreted with caution and await validation by future randomized controlled trials.