# Endoscopic Ultrasound‐Guided Hepaticogastrostomy With Plastic Stents in Comparison to Transpapillary Drainage With Metallic Stents for Unresectable Malignant Distal Biliary Obstructions

## TL;DR

This study compares two biliary drainage methods for unresectable malignant distal biliary obstructions and finds that adding a metallic stent to a plastic stent approach may be as effective as traditional metallic stent methods.

## Contribution

The study introduces a novel combination of plastic and metallic stents in hepaticogastrostomy as a viable alternative to traditional transpapillary drainage.

## Key findings

- HGS-PS had shorter procedure time but higher recurrence of biliary obstruction compared to EBS-MS.
- Adding a metallic stent to HGS-PS resulted in comparable time to recurrence as EBS-MS.
- Propensity score matching showed no significant differences in recurrence rates between the groups.

## Abstract

Endoscopic ultrasound‐guided hepaticogastrostomy (EUS‐HGS) is usually performed for unresectable malignant distal biliary obstruction (MDBO) when endoscopic retrograde cholangiopancreatography‐guided biliary stenting with fully covered self‐expandable metallic stents (EBS‐MSs) fails. We aimed to clarify the clinical outcomes of EUS‐HGS with plastic stents (HGS‐PSs) compared to EBS‐MS.

We retrospectively reviewed patients who underwent either HGS‐PS with or without antegrade stenting using MS (AS‐MS) or EBS‐MS as initial biliary drainage for unresectable MDBO between January 2017 and July 2024.

A total of 27 patients were included in the HGS‐PS group, and 128 patients were included in the EBS‐MS group. Median procedure time was significantly shorter for the HGS‐PS group (24 vs. 39 min, p < 0.001), and the incidence of adverse events was comparable (22% vs. 32%, p = 0.365). The HGS‐PS group had a significantly higher recurrent biliary obstruction (RBO) rate (48% vs. 26%, p = 0.002) and shorter time to RBO (TRBO) (169 vs. 341 days, p = 0.001). After propensity score matching, no significant differences were observed in either the RBO rate or TRBO. Subgroup analyses showed that TRBO was comparable between the HGS‐PS with AS‐MS and EBS‐MS groups (273 vs. 341 days, p = 0.609).

Although TRBO tended to be shorter for HGS‐PS compared to EBS‐MS, the addition of AS‐MS to HGS‐PS led to comparable TRBO, suggesting that this combination may be a viable alternative.

Clinical Trial Registration: The authors have confirmed clinical trial registration is not needed for this submission.