BACKGROUND AND AIM Few studies compared endoscopic ultrasound (EUS)-guided fine needle aspiration (EUS-FNA) with endoscopic retrograde cholangiopancreatography (ERCP)-based tissue sampling in terms of diagnostic accuracy in suspected malignant biliary obstruction. We evaluated and compared the diagnostic performance of EUS-FNA and ERCP-based tissue sampling.

METHODS This multicenter study included 263 patients with suspected malignant biliary obstruction who underwent same-session EUS and ERCP between 2012 and 2016.

RESULTS Malignancies were confirmed in 239 patients (90.9%) and benign in 24 patients (9.1%). Overall diagnostic sensitivity and accuracy were 73.6% and 76.1% for EUS-FNA, 56.5% and 60.5% for ERCP, and 85.8% and 87.1% for EUS/ERCP combination. EUS-FNA showed higher overall performances compared with ERCP (P < 0.001), whereas EUS/ERCP combination was superior to EUS-FNA alone (P-value < 0.001). EUS-FNA showed higher sensitivity and accuracy compared with ERCP for pancreatic masses (n = 187, both P-values < 0.001) but not for biliary lesions (n = 76, both P-values = 0.847). Sensitivity and accuracy of EUS/ERCP combination were superior to those of EUS-FNA for both pancreatic and biliary lesions (both P-values < 0.001). For patients with large mass (≥ 4 cm), there was no significant differences between ERCP/EUS combination and EUS-FNA (P-value = 0.31).

CONCLUSIONS Same-session EUS-FNA and ERCP combination was superior to EUS-FNA for both pancreatic masses and biliary lesions. Same-session EUS/ERCP combination can be considered a proper diagnostic method for suspected malignant biliary obstruction regardless of the origin of lesions. On the other hand, EUS-FNA alone was sufficient for diagnosis compared with EUS/ERCP combination in cases with large mass. Strategic diagnostic approach, according to clinical features of individual patient, is required.