Comparison of Biliary Drainage Techniques for Malignant Biliary Obstruction: A Systematic Review and Network Meta-Analysis

Abstract

Background: The various techniques for relief of malignant biliary obstruction include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD), and endoscopic ultrasound guided biliary drainage (EUS-BD). We conducted a systematic review and network meta-analysis (NMA) comparing all three modalities with respect to efficacy, adverse events, and re-intervention rate. Methods: We searched multiple databases from inception to October 2019 to identify comparative studies of malignant biliary obstruction patients treated with EUS-BD, ERCP or PTBD. Outcomes of interest were technical success, clinical success, adverse events and need for re-intervention. Pooled odds ratios (OR) were calculated and analyzed using the random effects model. To incorporate indirect comparisons, we conducted NMA using a multivariate, consistency model with random-effects meta-regression. We followed the GRADE approach to rate the certainty of evidence. Findings: We included 17 studies; of which 8 were randomized (3 EUS vs ERCP; 1 EUS vs PTBD; 13 ERCP vs PTBD) with 1566 patients (220: EUS vs ERCP; 33: EUS vs PTBD; 1313: ERCP vs PTBD). NMA did not show statistically significant differences to favor one intervention with certainty over the other across multiple outcomes. The analysis suggested that PTBD may have a higher clinical and technical success rate than ERCP and that EUS may have a lower re-intervention rate than ERCP. Interpretation: The available evidence cannot favor one of the 3 interventions with certainty across multiple outcomes. Shared-decision making is recommended to choose the approach most consistent with patient’s values, goals of treatment and comorbidities and consider the availability of procedural expertise. Funding: None. Conflict of Interest: None.