EUS-guided biliary drainage versus ERCP for the primary treatment of malignant distal biliary obstruction: time for a large randomized study

We read with great interest the 2 randomized controlled studies1,2 comparing EUS-guided biliary drainage (EUS-BD) versus ERCP as primary treatment of distal malignant biliary obstruction. Despite different primary outcomes (adverse event rate for Bang et al1 and stent patency duration for Park et al,2) both studies concluded that EUS-BD and ERCP were comparable regarding both primary outcomes and secondary outcomes (ie, technical and clinical success). However, although EUS-BD is a promising technique, we believe that both studies were not sufficiently powered to support their conclusion.

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