ERCP has long been regarded as the gold standard for biliary drainage in patients with malignant distal biliary obstruction (MDBO). However, ERCP carries certain drawbacks, including the risk of post-procedural pancreatitis and technical failure in cases with altered anatomy or an inaccessible papilla. In recent years, endoscopic ultrasound-guided biliary drainage (EUS-BD) has gained attention as a promising alternative, particularly with the development of dedicated devices such as lumen-apposing metal stents (LAMS).
Recent randomized controlled trials (RCTs) have demonstrated that EUS-BD offers comparable technical and clinical success rates to ERCP, with added advantages such as a lower incidence of pancreatitis and reduced need for reintervention. Nevertheless, disparities in healthcare systems, device availability, and endoscopist expertise across countries and institutions continue to influence the choice of drainage modality.
While EUS-BD is gaining ground as a complementary or even first-line option in high-volume Western centers, ERCP remains the more practical and accessible approach in many countries, including Japan. This presentation will provide an overview of the evolving role of EUS-BD and explore in which situations ERCP remains essential—taking into account not only anatomical and technical considerations, but also differences in healthcare infrastructure.