Learning Curve Of Endoscopic-Ultrasound Guided Biliary Duct Drainage : A Systematic Review and Meta-analysis

Background and Aims In recent years, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative to endoscopic retrograde cholangiopancreatography (ERCP). However, a recent meta-analysis of randomized controlled trials (RCTs) suggests comparable efficacy and safety between EUS and conventional ERCP for biliary drainage, highlighting the growing preference for EUS-BD. This study aims to contribute to this evolving landscape by investigating the technical and clinical success of EUS-BD and defining its learning curve. Methods A comprehensive search of electronic databases from January 2003 to November 2022 were searched for publications evaluating the learning curve of EUS-BD. Pooled proportions were calculated using both fixed and random-effects models, with a 95% confidence interval (C.I.). Results The initial search yielded 380 studies, of which 88 relevant articles were reviewed. Data from three studies (N=261) meeting inclusion criteria were analyzed. Proficiency in EUS-BD was achieved at 35.51 procedures. Pooled technical success was 92.45%, and clinical success was 84.84%. Adverse events occurred in 18.46% of cases, with specific rates for bleeding (4.31%), perforation (3.03%), sepsis (7.61%), procedure-related death (0.31%), and all-cause mortality (2.29%). No bias was detected using the Egger bias indicator which gave a value of -6.0 with a p value of 0.17 . Conclusions Our analysis reveals EUS-BD proficiency at around 35 procedures, with a mean post-proficiency procedure length of 68.07 minutes. Adverse events notably decrease after 66 procedures, informing a safety-driven recommendation: endosonographers should complete a minimum of 60 supervised procedures before independent EUS-BD practice, enhancing procedural safety and proficiency.