Optimal endoscopic drainage strategy for unresectable malignant hilar biliary obstruction

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Oncology

Background:

• Malignant hilar biliary obstruction presents complex management challenges.
• Endoscopic biliary drainage is a key intervention, but optimal strategies are debated.

Purpose of the Study:

• To review and clarify the optimal endoscopic biliary drainage strategy for unresectable malignant hilar biliary obstruction.
• To compare different stent types, drainage areas, and deployment methods.

Main Methods:

• Systematic review of previous studies on endoscopic biliary drainage.
• Comparative analysis of outcomes based on stent type (uncovered SEMS, covered SEMS, PS), drainage laterality (unilateral vs. bilateral), and deployment technique (side-by-side vs. stent-in-stent).

Main Results:

• Uncovered self-expandable metal stents (SEMS) demonstrate superior functional success rates, longer time to recurrent biliary obstruction (RBO), and reduced reintervention compared to plastic stents (PS).
• Bilateral SEMS placement is linked to longer RBO-free survival and overall survival than unilateral placement, though unilateral drainage is viable if >50% liver volume is achieved.
• No significant clinical outcome differences were noted between side-by-side (SBS) and stent-in-stent deployment methods; however, simultaneous SBS offers shorter procedure times and higher technical success.

Conclusions:

• Uncovered SEMS are recommended for managing malignant hilar biliary obstruction due to better long-term patency and fewer reinterventions.
• Bilateral drainage strategies should be considered for maximizing outcomes, with unilateral drainage as a feasible alternative under specific conditions.
• Simultaneous side-by-side deployment may be preferred for procedural efficiency and success.