Effectiveness and Safety of Enteroscopy‐Assisted ERP ‐Guided Versus EUS ‐Guided Pancreatic Duct Drainage for Pancreaticojejunostomy Strictures: A Multicenter Observational Study

OBJECTIVES: Enteroscopy-assisted endoscopic retrograde pancreatography-guided pancreatic duct drainage (eERP-PDD) and endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) are minimally invasive alternatives to surgery for pancreaticojejunostomy stricture (PJS); however, comparative data remain limited. We compared the effectiveness and safety of these approaches and identified factors associated with technical failure. METHODS: This multicenter retrospective study included 88 patients (111 procedures) who underwent endoscopic intervention for PJS at 13 Japanese tertiary centers. We compared clinical outcomes between eERP-PDD and EUS-PDD. The primary outcome was technical success; secondary outcomes included clinical success, procedure time, and adverse events (AEs). Propensity-score overlap weighting was used to adjust for baseline differences. RESULTS: As initial treatment, 77 patients underwent eERP-PDD and 11 underwent EUS-PDD. After adjustment, EUS-PDD achieved higher technical success (eERP-PDD, 28% vs. EUS-PDD, 71%; p = 0.012) and clinical success (22% vs. 71%; p = 0.003), with shorter procedure time (76 min vs. 41 min; p = 0.001). AE incidence was higher with EUS-PDD before adjustment (5% vs. 27%; p = 0.039) but comparable after adjustment (7% vs. 29%; p = 0.15); all AEs resolved with conservative management. Age < 75 years, male sex, and main pancreatic duct (MPD) diameter ≥ 5 mm were independently associated with eERP-PDD failure. CONCLUSIONS: EUS-PDD demonstrated higher technical and clinical success than eERP-PDD for PJS, with comparable safety after adjustment. An MPD diameter ≥ 5 mm was associated with eERP-PDD failure. An MPD-based algorithm is proposed: eERP-PDD for MPD < 5 mm with EUS-PDD as salvage, and EUS-PDD for MPD ≥ 5 mm. This algorithm is hypothesis-generating and requires prospective validation.