Malignant obstructive jaundice (MOJ) is a prevalent jaundice disorder in hepatobiliary surgery and gastroenterology. It is primarily attributed to the compression of malignant tumor cells (e.g., cholangiocarcinoma, pancreatic head carcinoma, ampullary cancer, etc.) on the relevant tissues of the patient, leading to constriction or even blockage of the bile ducts, bile stasis, and elevated bilirubin. Clinical manifestations encompass skin and scleral yellowing, pruritus, and clay-colored stools. With the rising incidence of biliary cancer, it poses a substantial adverse impact on the physical and mental well-being and daily activities of patients (1, 2).In clinical practice, obstructions from diverse sources can be classified as high and low biliary obstruction, with the intersection of the common hepatic duct and the cystic duct serving as the demarcation point. Hilar tumors typically give rise to high obstructions, while ampullary and peripancreatic tumors commonly result in low obstructions (3).

Currently, the most effective treatment for this disease is surgical resection. Malignant obstructive jaundice caused by malignant tumors of the biliary tract or metastatic carcinomas of the hepatic hilum, particularly biliary cancer jaundice, often lacks specific clinical manifestations in the early stages. Consequently, most patients have missed the opportunity for surgery by the time MOJ emerges (4). With the advancement of interventional therapy techniques, palliative interventional therapy has emerged as the most effective approach to alleviate MOJ. It can effectively reduce the bilirubin level in the blood, safeguard liver function, alleviate jaundice, and enhance the quality of life (5). Percutaneous transhepatic cholangial drainage (PTCD) and endoscopic retrograde cholangiopancreatography (ERCP) form the foundation of palliative intervention (6). PTCD entails the insertion of a percutaneous puncture needle into the intrahepatic bile ducts, followed by the injection of contrast material to visualize the intrahepatic and extrahepatic bile ducts, and subsequent biliary drainage (7). ERCP involves the placement of an endoscope through the patient’s mouth and esophagus into the descending part of the duodenum to locate the opening of the bile ducts and insert a drainage tube. This tube passes through the duodenal papilla to enter the bile ducts for drainage (8).

Currently, there is no consensus regarding the effectiveness of these two treatment options. Domestic and international scholars have systematically assessed the efficacy of PTCD and ERCP in the treatment of MOJ applications, but specific analyses of the efficacy and safety based on the site of obstruction have not been conducted. Therefore, the study aims to compare the clinical efficacy and surgical safety of the two drainage methods, PTCD and ERCP, in the treatment of patients with MOJ with different sites of obstruction, in order to provide a medical basis for clinical treatment.

Malignant obstructive jaundice is caused by direct or indirect stricture or occlusion of intrahepatic and extrahepatic bile ducts due to malignant tumors, resulting in obstruction of bile excretion and stasis, which can lead to a series of serious complications such as hyperbilirubinemia, coagulation dysfunction, liver and kidney dysfunction (30, 31). The common causes of MOJ include primary bile duct cancer, gallbladder cancer, liver cancer, pancreatic cancer and periampullary cancer, which cause metastasis or invasion of the bile ducts. Due to its high degree of malignancy, it can pose a threat to the life of patients if not treated in a timely manner. The related treatment is usually palliative, and the main purpose of treatment is to improve the liver function of patients (32). Currently, different studies have demonstrated that both PTCD and ERCP are effective and safe.

In this study, a total of 21 RCTs were selected through two search pathways to systematically evaluate the efficacy and safety of PTCD and ERCP in the treatment of MOJ. When reviewing the included literature of similar related Meta-analyses published in the past, it was discovered that in the study of GH Bao et al. (33), which had been included in previous Meta-analyses, the specific grouping principles were not mentioned. Instead, it was simply divided into two groups based on the treatment method or the patients’ voluntary choice of surgery, raising suspicions of a grouping bias caused by the patients’ knowledge background or other factors. The possibility of nonrandomization was considered to be high. Therefore, it did not meet the principle of inclusion of randomized controlled trials in this study and was not included.

The comparison of efficacy in this study indicates that: (1) There is no significant difference in the surgical success rate between the two procedures in patients with low-level obstruction, but the overall surgical success rate and the success rate in patients with high-level obstruction via PTCD are higher. This may be due to the fact that, compared to ERCP, PTCD requires direct puncture of the hepatic parenchyma, resulting in a shorter path to the site of the obstruction. The influencing factors of PTCD include: whether the patient can tolerate the operation, whether the guide wire can successfully pass through the bile duct stenosis, and the number of stents placed. The influencing factors of ERCP include the ability to successfully identify the duodenal papilla endoscopically, the ability of the guide wire to successfully pass through the biliary stricture, and the skill of the operator (34). Some studies have also reported a failure rate of up to 10% for ERCP procedures,and PTCD is often used as an alternative in cases of ERCP failure (35). (2) There was no significant difference in the overall jaundice remission rate and clinical efficacy between PTCD and ERCP, but depending on the site of obstruction, ERCP maneuvers were more effective in patients with low obstructions, while PTCD was better in jaundice remission in patients with high obstructions. (3) There was no significant difference in ALT, TBIL and DBIL before and after operation between the two groups. In conclusion, the success rate of PTCD is higher than that of ERCP, and it can be recommended as the first choice of treatment or as a remedy after the failure of ERCP treatment. Both surgical procedures have a certain efficacy in reliving jaundice and improving liver function. In practice, we can analyze the specific conditions of the patients and try to choose the most reasonable treatment plan.

Any interventional procedure is invasive, and the efficacy is accompanied by the risk of complications. Both procedures may lead to a number of complications. The main complications of PTCD are bleeding and biliary tract infection. The main cause of bleeding is the obscuration of the puncture path of PTCD and the inadvertent puncture of the patient’s blood vessels during the puncture. The bleeding is caused by the blinding of the puncture path of PTCD, and inadvertent puncture of the patient’s blood vessels during the puncture (36). The infection may be secondary to the reflux of duodenal fluid or to an associated poor drainage process, while ERCP is more likely to cause acute pancreatitis (37). Some scholars have also reported that the incidence of postoperative complication rates is as high as 30% to 50% for PTCD, compared to only about 5% for ERCP (38). The results of the meta-analysis showed that although the overall complication rate was higher in the PTCD group than in the ERCP group, it was not statistically significant, which is inconsistent with the results of some previous studies (39, 40). It may be due to the uneven grouping of some studies, which led to a bias towards patients with high levels of obstruction. These patients have greater difficulty in performing ERCP, thus increasing the complication rate in the ERCP group. However, the results of these studies may also be related to geographic areas, target populations, sample sizes, and other factors.

The shortcomings of this study are as follows: Through the search and screening, only a limited number of literatures were included, and fewer relevant RCT studies from abroad were retrieved that met the criteria. In addition, the inclusion of literature did not specify the blinding and allocation concealment, which may be subject to bias.

In summary, this study indicates that both ERCP and PTCD have comparable clinical effectiveness in treating MOJ, as they can both effectively alleviate jaundice and reduce biliary obstruction. The overall success rate of PTCD is higher than that of ERCP, while the incidence of postoperative complications is slightly lower. A more suitable treatment option can be chosen based on the location of the obstruction. PTCD shows better clinical outcomes in patients with high obstruction, while ERCP performs better in those with low obstruction.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/ Supplementary Material .

YW: Conceptualization, Methodology, Data analysis, Writing – original draft, Writing – review & editing. XC: Conceptualization, Methodology, Writing – review & editing. XZ: Writing – original draft, Writing – review & editing. YS: Writing – original draft. QK: Writing – original draft.