CHOLEBLADEUS: long-term results of endoscopic ultrasound-guided gallbladder versus bile duct drainage of malignant biliary obstruction after failed ERCP: a propensity-matched study.

BACKGROUND : Endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) is emerging as an alternative to choledochoduodenostomy (EUS-CDS) for malignant distal biliary obstruction (MDBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Comparative data on long-term patency are limited. METHODS : This retrospective international study analyzed two historical cohorts of patients who underwent EUS-GBD or EUS-CDS for MDBO after failed ERCP between March 2017 and May 2024. Eligible patients were aged ≥ 18 years with at least 6 months' follow-up or confirmed death. The primary outcome, after 1 : 1 propensity score matching, was 12-month biliary patency. Secondary outcomes included technical and clinical success, adverse events (AEs), reintervention rates, and overall survival. RESULTS : Before matching, 294 patients were included (142 EUS-GBD; 152 EUS-CDS). After matching, 200 patients were analyzed (100 per group). Technical success was 100 % for EUS-GBD and 97 % for EUS-CDS (P = 0.25). Clinical success was 80.5 % for EUS-GBD and 90.6 % for EUS-CDS (P = 0.08). At 12 months, the probability of biliary patency was significantly higher with EUS-GBD than EUS-CDS (86.2 % [95 %CI 74.2 %-92.9 %] vs. 63.8 % [95 %CI 49.5-75.0]; P = 0.01). Biliary reintervention-free survival was significantly longer with EUS-GBD (log-rank, P < 0.001). Periprocedural AEs occurred in 7.0 % vs. 10.0 % (P = 0.61), delayed AEs in 27.0 % vs. 30.0 % (P = 0.75), and reintervention rates were comparable (23.0 % vs. 26.0 %; P = 0.74). Overall survival did not differ significantly (log-rank, P = 0.59). CONCLUSION : In patients with MDBO after failed ERCP, EUS-GBD achieved higher 12-month biliary patency than EUS-CDS, with comparable rates of technical and clinical success, morbidity, reintervention, and overall survival.