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

ABSTRACT Objectives 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. Methods 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. Results 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). Conclusions 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.