EUS-Guided Choledochoduodenostomy with Lumen-Apposing Metal Stent versus ERCP with Self-Expandable Metal Stent as Primary Biliary Drainage for Malignant Distal Biliary Obstruction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Whether endoscopic ultrasound guided choledochoduodenostomy (EUS CDS) with lumen apposing metal stent (LAMS) is superior to endoscopic retrograde cholangiopancreatography (ERCP) with self expandable metal stent (SEMS) as primary drainage for malignant distal biliary obstruction (MDBO) remains uncertain. We conducted a meta analysis of randomized controlled trials (RCTs) to compare their efficacy and safety. Methods: A systematic search of CENTRAL, PubMed, and Embase through September 11, 2026 was conducted. GRADE and trial sequential analysis (TSA) were performed. Results: Three high quality RCTs comprising 519 patients were included. Moderate certainty evidence showed EUS CDS with LAMS was associated with higher technical success (RR 1.18, 95% CI 1.09 to 1.28, P < 0.0001), shorter procedure time (P < 0.00001), and lower postprocedural pancreatitis risk (P = 0.01) than ERCP, with comparable clinical success and overall adverse events. Sensitivity analysis, cumulative meta analysis, and TSA supported the results. Conclusions: EUS CDS with LAMS may be considered as an alternative primary biliary drainage for MDBO.