Endoscopic Choledochoduodenostomy versus Gallbladder Drainage for Malignant Biliary Obstruction: A Propensity Score Matched Study

Abstract Introduction: Endoscopic ultrasound-guided gallbladder drainage (EUS-GB) is an emerging alternative to choledochoduodenostomy (EUS-CBD) for malignant distal biliary obstruction (MDBO), particularly when conventional access is not feasible. Methods: We conducted a multicenter, retrospective study of patients undergoing EUS-GB or EUS-CBD for MDBO between January 2015 and October 2024. Primary outcomes were technical and clinical success. Secondary outcomes included procedural time, 6-month reintervention, adverse events (AEs), and all-cause mortality. Propensity score matching (PSM) was used to adjust for baseline differences. Results: Eighty-two patients were included (22 EUS-GB, 60 EUS-CBD). Technical success was comparable between groups (95.5% vs. 96.7%). EUS-GB was used as salvage in 50% of cases when EUS-CBD was not feasible, with a 90.9% technical success rate. PSM yielded 21 matched pairs. Clinical success was similar (95.2% EUS-GB vs. 85.7% EUS-CBD, p=0.61). EUS-CBD had significantly lower 6-month reintervention (4.8% vs. 23.8%, p=0.004) and stent-related complications (0% vs. 18.9%). Adverse event rates and all-cause mortality were similar. Median follow-up was 116 days (IQR: 51–300). In the EUS-GB group, pre-procedural cystic duct patency predicted clinical success (94.1%). Conclusion: EUS-GB is a technically effective and clinically comparable alternative to EUS-CDS for MDBO, with significantly fewer reinterventions and stent-related complications. When cystic duct patency is confirmed on imaging, EUS-GB may be considered as a primary approach or salvage strategy for biliary drainage in MDBO.