EUS-HGS with antegrade stenting vs. hepaticogastrostomy alone for malignant biliary drainage: Systematic review and meta-analysis

Background and study aims: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective and safe therapeutic option for biliary drainage in patients with malignant biliary obstruction (MBO). Several authors proposed use of antegrade stenting (AS) combined with EUS-HGS to improve long-term outcomes, with controversial results. We aimed to assess pooled performance of EUS-HGS+AS compared with EUS-HGS alone. Methods: Database search was performed to identify studies comparing EUS-HGS+AS to EUS-HGS alone for biliary drainage in patients with MBO. Primary outcome was recurrent biliary obstruction (RBO). Secondary outcomes were technical, clinical success, adverse events (AEs), severe AEs rate, time to RBO, and overall survival (OS). Relative risks (RRs) with 95% confidence intervals (CIs) were calculated using random-effect model. Results: Five studies involving 555 patients were retrieved. RBO was lower in patients who underwent EUS-HGS+AS (RR 0.30; [0.18-0.49]; P < 0.001). Pooled technical success, clinical success, AE, and severe AE rates were similar (RR 0.94 [0.85-1.05], RR 1.02 [0.94-1.11], RR 0.88 [0.50-1.55]), and 0.26 [0.03-2.22], respectively). Time to RBO was higher in EUS-HGS+AS (SMD + 4.02 [0.57-7.47]; P = 0.04). Mean procedure time was similar among the groups (SMD +0.38 [-0.12-0.87]; P = 0.13) as well as OS was similar in the two groups (SMD 0.18 [-0.20-0.52]; P = 0.85). Conclusions: Combining AS with EUS-HGS reduces RBO risk in patients with MBO, without impact on technical, clinical success rates, or safety profile. Randomized controlled trials are needed to confirm these observations.