Learning curve of EUS-guided biliary duct drainage: systematic review and meta-analysis.

Background and Aims: In recent years, EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to ERCP. However, a recent meta-analysis of randomized controlled trials 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 was conducted from January 2003 to November 2022 for publications evaluating the learning curve of EUS-BD. Pooled proportions were calculated using both fixed-effects and random-effects models, with a 95% confidence interval. Results: The initial search yielded 380 studies, of which 88 relevant articles were reviewed. Data from 3 studies (261 patients) 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 (.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 Conclusions: Our analysis revealed an EUS-BD proficiency at around 35 procedures, with a mean postproficiency 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.