Endoscopic ultrasound‐guided hepaticogastrostomy versus hepaticogastrostomy with antegrade stenting for malignant distal biliary obstruction

Background Recurrent biliary obstruction (RBO) is a possible complication of endoscopic ultrasound‐guided hepaticogastrostomy (EUS‐HGS) in patients with malignant distal biliary obstruction (MDBO). Therefore, adding antegrade stenting across MDBO, followed by EUS‐HGS (EUS‐HGAS), may prolong the time to RBO (TRBO). We aimed to compare the outcomes of EUS‐HGS and HGAS. Methods We retrospectively evaluated consecutive patients who underwent EUS‐HGS or HGAS between July 2016 and November 2020. The TRBO, overall survival (OS), and adverse event (AE) rate were compared between the groups. The risk factors for RBO were determined using a multivariable Cox proportional hazards model. Results This study included 96 patients (EUS‐HGS, n = 58; HGAS, n = 38). There was a significant difference in the cause of endoscopic retrograde cholangiopancreatography failure and the HGS stent type between the groups. A significant difference was found in TRBO (234 days vs not reached, P = .036), whereas no significant difference was found in the OS (123 vs 126 days, P = .76). The AE rate was not significantly different. Multivariable analysis revealed that EUS‐HGS was an independent risk factor for RBO (hazard ratio: 4.01, 95% confidence interval: 1.16‐13.9). Conclusions Endoscopic ultrasound‐guided hepaticogastrostomy prolonged the TRBO compared with EUS‐HGS for biliary drainage in patients with MDBO. HighlightAdding antegrade stenting to endoscopic ultrasound‐guided hepaticogastrostomy prolonged the time to recurrent biliary obstruction and reduced the risk of peritonitis. While the risk of pancreatitis may be a disadvantage of antegrade stenting, Ishiwatari and colleagues conclude that, especially for patients with longer life expectancy, adding antegrade stenting may be useful.