Resumen
With the widespread use of EUS-guided procedures, several methods are available in order to achieve biliary drainage when endoscopic retrograde cholangiopancreatography (ERCP) fails. Together with the well established role of percutaneous trans-hepatic biliary drainage (PTBD) and surgical hepaticojejunostomy, EUS-choledochoduodenostomy (EUS-CD) and EUS-hepaticogastrostomy (EUS-HG) have provided good results to date, representing valuable alternatives. However, no definite indications have been provided about which should be the best way of drainage. In this network meta-analysis, we compared all these techniques, showing how, considering the available studies, none of these methods seems to be superior to another, although PTBD seems to have a slightly higher rate of adverse events. So, when dealing with patients affected by distal malignant biliary obstruction (DMBO) and when ERCP fails, all these methods seem to be equally effective, although possibly EUS-guided approaches could be less invasive and affected by fewer adverse events.