Palliative endoscopic biliary drainage for malignant hilar biliary obstruction

Shuji Mitsuhashi; Manik Aggarwal; Vinay Chandrasekhara

doi:10.5946/ce.2025.395

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Review Palliative endoscopic biliary drainage for malignant hilar biliary obstruction: Shuji Mitsuhashi^,*, Manik Aggarwal^,*, Vinay Chandrasekhara; DOI: https://doi.org/10.5946/ce.2025.395
Published online: March 31, 2026

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA

Correspondence: Vinay Chandrasekhara Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA E-mail: chandrasekhara.vinay@mayo.edu

*Shuji Mitsuhashi and Manik Aggarwal contributed equally to this work as co-first authors.

• Received: October 26, 2025 • Revised: December 10, 2025 • Accepted: December 11, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
CLASSIFICATION AND ANATOMY
INDICATIONS FOR DRAINAGE
ENDOSCOPIC VERSUS PERCUTANEOUS BILIARY DRAINAGE
PRE-PROCEDURE PLANNING
STENT SELECTION IN THE CURRENT ERA
SECTORAL DRAINAGE STRATEGY
ADJUVANT THERAPIES
ENDOSCOPIC ULTRASOUND-GUIDED BILIARY DRAINAGE
SPECIAL POPULATIONS
FUTURE DIRECTIONS
CONCLUSIONS
NOTES
REFERENCES

Abstract

Malignant hilar biliary obstruction (MHBO) is most commonly caused by cholangiocarcinoma or gallbladder cancer and frequently presents with obstructive jaundice, pruritus, and/or cholangitis. These symptoms impair performance status and delay the initiation of chemotherapy, making biliary drainage essential for both palliation and oncologic treatment. Endoscopic transpapillary biliary stenting via endoscopic retrograde cholangiopancreatography is the standard approach for biliary decompression. In patients with unresectable disease, either plastic or self-expandable metal stents may be used. Optimal outcomes are achieved when drainage encompasses more than 50% of functional liver volume, while atrophic segments should be avoided. When transpapillary access is not feasible or unsuccessful, alternative approaches such as percutaneous transhepatic biliary drainage or endoscopic ultrasound-guided biliary drainage may be considered. Adjunctive therapies, including photodynamic therapy and radiofrequency ablation, are being investigated to enhance local tumor control and prolong stent patency. With continued advances in stent technology, imaging modalities, and endoscopic techniques, the management of MHBO is expected to become increasingly individualized and effective.
Keywords: Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound-guided biliary drainage; Malignant hilar biliary obstruction; Palliative endoscopy; Self-expanding metal stents

INTRODUCTION

Malignant hilar biliary obstruction (MHBO) is a complex clinical condition that most commonly results from perihilar cholangiocarcinoma (CCA) or advanced gallbladder cancer. Obstruction at the hepatic duct confluence can cause jaundice, cholangitis, pruritus, and hepatic dysfunction, leading to deterioration in performance status and delays in initiating oncologic therapy. Therefore, effective biliary drainage is a cornerstone of palliative management, aimed at relieving symptoms, preventing infection, and enabling treatment with systemic chemotherapy. Endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stenting, using either plastic stents (PSs) or self-expanding metal stents (SEMSs), remains the standard approach for biliary decompression. However, MHBO poses unique technical challenges due to complex ductal anatomy and the frequent need for multisegmental drainage. Advances in endoscopic techniques and devices have improved the feasibility and durability of endoscopic palliation. In cases where ERCP is not feasible or unsuccessful, percutaneous transhepatic biliary drainage (PTBD) and endoscopic ultrasound-guided biliary drainage (EUS-BD) serve as important alternative strategies.¹^-⁴ This review summarizes current evidence and clinical considerations in the endoscopic management of MHBO, emphasizing individualized, anatomy-based planning and emerging technologies aimed at optimizing patient outcomes.

CLASSIFICATION AND ANATOMY

Effective management of MHBO requires a thorough understanding of biliary anatomy and precise tumor classification. The Bismuth-Corlette classification remains the most widely used system for categorizing hilar tumors based on the extent of ductal involvement (Fig. 1). Type I tumors involve the common hepatic duct below the confluence; type II tumors reach the confluence but do not extend into the right or left hepatic ducts; types IIIa and IIIb tumors extend into the right and left hepatic ducts, respectively; and type IV tumors involve both ductal systems bilaterally. Higher Bismuth types are associated with²^,⁵^,⁶ greater technical difficulty in achieving adequate biliary drainage, particularly for types III and IV, which often require bilateral or multisegmental stenting.

A detailed understanding of hepatic sectoral anatomy is equally essential. The right anterior, right posterior, and left hepatic sectors each contribute approximately 30% of total liver volume, while segments I and IV together account for the remaining 10%. Cross-sectional imaging—preferably contrast-enhanced computed tomography (CT) or magnetic resonance imaging with magnetic resonance cholangiopancreatography (MRCP)—is essential for delineating biliary and vascular anatomy, detecting lobar atrophy, and assessing resectability. Effective biliary drainage should target decompression of at least 50% of the functional liver volume, which is associated with greater bilirubin reduction, decreased risk of cholangitis, and improved survival. Drainage of atrophic or tumor-infiltrated segments should be avoided, as such intervention increases the risk of cholangitis without providing meaningful clinical benefit. Findings such as vascular encasement, bilateral secondary duct involvement, and contralateral lobar atrophy typically indicate unresectability and support a palliative drainage strategy.²^,³^,⁵

INDICATIONS FOR DRAINAGE

The principal indication for biliary drainage in MHBO is the palliation of symptoms, including jaundice, pruritus, cholangitis, and hepatic dysfunction. In patients with unresectable disease who are candidates for systemic therapy, biliary decompression is critical for lowering bilirubin levels, improving hepatic function, reducing the risk of infection, and facilitating the initiation of chemotherapy. Timely drainage in this population may also improve performance status and enable consideration for clinical trial enrollment. Conversely, for asymptomatic patients with poor functional status or no planned oncologic therapy, the benefit of biliary drainage is less certain, particularly when imaging reveals high procedural risk, complex biliary anatomy, or the presence of nonviable liver segments. In such cases, a conservative approach may be more appropriate, and the risks of intervention, including cholangitis, bleeding, and liver failure, must be carefully weighed against the potential clinical benefits. Ultimately, the decision to perform biliary drainage should be individualized and guided by the patient’s symptom burden, prognosis, and goals of care, with a clear understanding that not all patients with MHBO require immediate or aggressive decompression.²^,³^,⁷

ENDOSCOPIC VERSUS PERCUTANEOUS BILIARY DRAINAGE

Traditional management of malignant biliary obstruction relies on both PTBD and endoscopic biliary drainage (EBD), typically via ERCP. Historically, PTBD was favored for its higher technical success and perceived lower adverse event (AE) rates, particularly in hilar strictures. Recent randomized controlled trials (RCTs) and meta-analyses continue to demonstrate that PTBD achieves higher technical success rates in the palliation of hilar strictures. For example, a meta-analysis of 21 RCTs including 1,693 patients reported that PTBD had significantly greater technical success than ERCP for decompression of hilar biliary obstruction (p<0.0001).⁸ In palliative settings, however, both PTBD and EBD remain effective for achieving biliary decompression and enabling oncologic therapy.⁸^-¹²

Despite its technical advantages, PTBD is associated with higher rates of AEs, including bleeding, bile leak, and infection, as well as increased 30-day mortality. A large national cohort study reported a 30-day mortality rate of 23.1% following PTBD for malignant biliary obstruction, with AEs occurring in up to 20% of patients. PTBD also carries a risk of tumor seeding along the catheter tract, which is particularly relevant in resectable malignancies. In contrast, EBD carries a higher risk of post-ERCP pancreatitis and cholangitis, but overall AE rates are generally lower.¹³^,¹⁴ In one national cohort, EBD was associated with fewer AEs than PTBD (8.6% vs. 12.3%), as well as shorter hospital stays and reduced costs. Furthermore, PTBD often necessitates external drainage, which can negatively impact patient comfort and quality of life.¹⁵

Overall, current guidelines from the American College of Gastroenterology (ACG), the American Society for Gastrointestinal Endoscopy (ASGE), and the Asia-Pacific Consensus recommend EBD as the first-line approach due to its advantages in patient comfort, diagnostic capability, and lower metastatic risk. PTBD should be reserved for cases where EBD is not feasible, has failed, or when complex hilar anatomy requires greater technical precision. Ultimately, the choice of drainage modality should be individualized based on biliary anatomy, institutional expertise, and patient preferences.²^-⁴

PRE-PROCEDURE PLANNING

EBD in patients with MHBO requires meticulous preprocedural planning to optimize outcomes and minimize complications. High-resolution cross-sectional imaging, preferably with MRCP, should be performed to delineate biliary anatomy, evaluate the extent of obstruction, and assess atrophic or tumor-infiltrated liver segments. Contrast-enhanced CT is an appropriate alternative when MRCP is unavailable. These imaging findings guide ductal access, stent selection, and drainage targets.²^,³^,⁶^,¹⁶ Periprocedural antibiotics are essential in all patients undergoing drainage for hilar strictures due to the high risk of cholangitis, particularly when drainage is incomplete. To further reduce AEs, contrast injection and guidewire access should be limited to the intended drainage sectors, as unintended opacification of undrained ducts is a recognized risk factor for infection.¹⁶^,¹⁷ Technical considerations, such as stricture predilation, biliary sphincterotomy, and stent selection, should be individualized based on procedural complexity and ductal anatomy. Careful guidewire management and precise ductal mapping are critical when multiple stents are required. In select cases, diagnostic cholangiography during ERCP or PTBD can further clarify complex hilar anatomy and assist in wire placement.²^,³

A comprehensive preprocedural assessment that incorporates imaging, liver function evaluation, and multidisciplinary discussion is essential for defining a safe and effective drainage approach. While drainage planning is guided by volumetric principles and sectoral anatomy, as discussed in the following section, pre-procedure planning establishes the foundation for its successful execution.²^,³^,¹⁷

STENT SELECTION IN THE CURRENT ERA

The choice between PS and SEMS is a critical consideration in EBD for MHBO, where complex biliary anatomy requires meticulous procedural planning. Table 1 summarizes clinical outcomes from comparative studies, highlighting key differences in technical and clinical success, time to recurrent biliary obstruction, AE rates, and overall survival.¹⁸^-²⁶ Optimal stent selection should be individualized, considering ductal anatomy, expected survival, procedural feasibility, the need for reintervention or future conversion to alternative drainage strategies, and resource availability.

The paradigm of stent selection has evolved in parallel with advances in oncologic care that have improved overall survival. Recent advancements in oncologic treatment modalities, including chemotherapy, immunotherapy, and targeted therapies, have significantly prolonged survival in patients with advanced biliary tract cancers, including hilar CCA.¹^,²⁷ Accordingly, drainage strategies must be reconsidered to ensure durable yet revisable biliary decompression throughout prolonged treatment courses. Although uncovered SEMSs were once routinely used, contemporary oncologic therapies have enabled some patients to outlive their typical patency period of 6–12 months, resulting in subsequent biliary obstruction.²⁴^,²⁸^,²⁹ Recurrent biliary obstruction due to tumor ingrowth through uncovered SEMS at the hilum is significantly more challenging to manage than recurrent obstruction involving uncovered SEMS placed in the distal bile duct.³^,¹⁶

Patients planned for oncologic treatments

In patients scheduled to receive systemic oncologic therapy, maintaining a biliary drainage system that enables safe and reliable reintervention is critical. PSs are generally favored in this setting because they permit individualized sectoral drainage in complex perihilar strictures, can be readily exchanged, and accommodate changes in ductal anatomy or tumor response over time. This approach supports durable biliary decompression while minimizing procedural complexity during repeated interventions or successive chemotherapy cycles. Additionally, PSs permit individualized sectoral drainage in complex perihilar strictures, are relatively easy to exchange, and are less expensive upfront. Across multiple comparative studies (Table 1), technical success rates for both PS and SEMS have been high, typically approaching or reaching 100%, indicating that both stent types can be reliably deployed in experienced hands.¹⁹^-²⁶

Figure 2 shows a practical summary of stent selection considerations. Factoring in the feasibility of routine exchange, our practice has been to establish initial biliary drainage with PS through a multidisciplinary, shared decision-making approach. Long PS can be used to maximize drainage of viable hepatic segments, particularly in complex hilar strictures, and scheduled exchanges can help preserve their effectiveness. PS also offers technical advantages, including shorter procedural time and easier access for revision in the event of dysfunction. We continue routine scheduled PS exchanges every 10–12 weeks (sooner with smaller-caliber stents) in patients demonstrating a favorable response to oncologic therapy. This iterative approach is recommended for Bismuth type II–IV strictures and is supported by the Asia-Pacific consensus guidelines.²^,⁴^,²⁴^,²⁶^,²⁸^,²⁹

Palliative and short-survival scenarios

SEMSs are generally reserved for patients with a short, expected survival of less than 3–6 months who prefer to avoid repeat ERCPs and whose anatomy permits durable stent deployment. Before SEMS placement in the hilar region, a careful review of the patient’s clinical trajectory, eligibility for clinical trials, and personal preferences is essential. Covered SEMSs are generally avoided due to the risk of occluding adjacent ducts, whereas uncovered SEMSs may be placed in parallel or Y-shaped configurations to achieve bilateral drainage. These advanced techniques demand high procedural expertise and precise imaging to prevent undrained segments and minimize complications.²^,³^,²⁴^,²⁸

SECTORAL DRAINAGE STRATEGY

After selecting the appropriate stent type, the drainage strategy for MHBO should be guided by volumetric and anatomical considerations rather than by the traditional classification of unilateral versus bilateral stenting. The 2024 ACG guidelines emphasize a paradigm shift toward sectoral, volume-based drainage, with the objective of decompressing more than 50% of the non-atrophic liver parenchyma. This threshold has been associated with improved jaundice resolution, reduced cholangitis rates, and better tolerance of systemic therapy.²

To guide this approach, the liver is anatomically divided into three main sectors: the right anteromedial sector (segments V and VIII), right posterolateral sector (segments VI and VII), and left lateral sector (segments II and III), each contributing approximately 30% of total hepatic volume. Segments I and IV account for the remaining 10%. The technical goal is to achieve drainage of at least two viable sectors—whether within a single lobe or across lobes—as this corresponds to decompression of over 50% of the liver volume.²^,³ Figure 3 illustrates an example of bilateral PS placement for sectoral drainage in a patient with a perihilar stricture.

Historically, several studies have attempted to compare unilateral and bilateral stenting approaches. One RCT and two meta-analyses reported no significant difference in drainage success between unilateral and bilateral SEMSs.²⁹^,³⁰ However, another RCT demonstrated that bilateral SEMS placement resulted in significantly fewer reinterventions (42.6% vs 60.3%, p=0.049) and longer median stent patency (252 vs. 139 days, p<0.01) compared with unilateral SEMS.³¹ These findings, however, must be interpreted with caution due to heterogeneity in included stricture types (e.g., exclusion of Bismuth IV lesions), variability in stent deployment techniques (side-by-side vs. stent-in-stent), and anatomical complexities, such as right sector drainage via the left hepatic duct. Additionally, many studies lacked volumetric liver assessments, limiting the generalizability of their conclusions.

Given these limitations, a growing consensus suggests that the volume of liver drained is a more meaningful predictor of outcomes than stent laterality. A retrospective multicenter study found that draining more than 50% of liver volume was the strongest independent predictor of clinical success (odds ratio [OR], 4.5; p=0.001) and was associated with longer survival (median, 119 vs. 59 days; p=0.005).⁶ Another study demonstrated that draining at least two hepatic sectors was significantly associated with higher clinical success (OR, 8.5; 95% confidence interval [CI], 2.7–26.7; p<0.001), whereas labeling drainage as “unilateral” or “bilateral” was not predictive of outcome.⁵

In individuals with advanced hilar CCA receiving systemic chemotherapy, the extent of biliary drainage must be individualized to permit oncologic therapy. Even with bilateral stenting and normalized bilirubin levels, undrained or partially drained sectors can still lead to the development of cholangitis or biliary abscesses during chemotherapy, often causing treatment interruptions. This underscores the importance of achieving “functional” drainage that provides effective biliary decompression tailored to each patient’s anatomy and clinical scenario.²^,⁵^,³² In this setting, a tailored, sectoral approach that decompresses all non-atrophic and chemotherapy-relevant sectors while minimizing contrast opacification of undrained ducts may offer the optimal balance between oncologic efficacy and procedural safety.

Consequently, recent societal and consensus guidelines have moved beyond the traditional unilateral versus bilateral framework, instead endorsing a sectoral, anatomy-based strategy. The shared goal is to decompress more than 50% of the functional liver volume by draining at least two viable sectors. For patients receiving systemic therapy, achieving effective drainage across essential sectors is especially critical to prevent chemotherapy interruptions and optimize survival outcomes. This volumetric approach represents a contemporary, evidence-based paradigm for improving outcomes in patients with complex MHBO.²^-⁴

ADJUVANT THERAPIES

Photodynamic therapy

Photodynamic therapy (PDT) is a palliative treatment modality for unresectable MHBO, particularly in patients with hilar CCA. The procedure involves the intravenous administration of a porphyrin-based photosensitizer, typically porfimer sodium (Photofrin (Pinnacle Biologics Inc.) 2 mg/kg), which selectively accumulates in malignant tissue. After a 24–48 hours drug-light interval, photoactivation is performed via endoscopic laser light delivery, inducing tumor necrosis through localized photochemical cytotoxicity. During the procedure, ERCP is used to delineate biliary anatomy and position the treatment catheter (Fig. 4). Light delivery is achieved using a 2.5 cm cylindrical diffuser at the tip of a translucent triple-lumen cannula (Pioneer Optics), connected to a diode laser system (InGaAIP Laser Diode; Diomed Inc.) operating at a wavelength of 633±3 nm with a maximum output of 2,000 mW. Photoactivation is typically performed at 630 nm, delivering 180 J/cm² at 0.25 W/cm² over 750 seconds. For long strictures, a pull-back technique allows stepwise, non-overlapping treatment under fluoroscopic guidance. Plastic biliary stents are routinely placed to prevent cholangitis secondary to post-treatment edema. PDT is often repeated every 3 months alongside scheduled stent exchanges.²^,³³^,³⁴

Although PDT is not considered a standard adjuvant therapy following resection, interest is growing in its use as a neoadjuvant strategy to downstage initially unresectable hilar tumors. In a phase II pilot study, neoadjuvant PDT followed by surgery 6 weeks later enabled R0 resection in all seven patients with previously unresectable hilar CCA. Five-year survival was 43%, with a median post-resection survival of 3.2 years, comparable to outcomes in patients undergoing upfront curative resection. These preliminary findings support the potential role of neoadjuvant PDT in select cases, although larger confirmatory studies are needed.³⁵^,³⁶

For unresectable hilar obstructions, PDT combined with biliary stenting has consistently demonstrated survival benefits compared with stenting alone. For example, multiple meta-analyses report a pooled median survival of 11.9–14.2 months with PDT plus stenting versus 6.7–9.8 months with stenting alone, with statistically significant differences.³⁷^-³⁹ Additionally, prospective studies have shown that PDT prolongs metal stent patency (median, 244 vs. 177 days; p=0.02) and improves biliary drainage efficacy without increasing AEs.³²^,⁴⁰ Furthermore, combination regimens have demonstrated additive benefits. In a randomized phase II trial, adding oral S-1 chemotherapy to PDT further improved median survival to 17 months versus 8 months with PDT alone (hazard ratio [HR], 0.36; 95% CI, 0.17–0.75).⁴¹ Moreover, combining PDT with systemic chemotherapy has shown synergistic effects, with median survival extending to 17–20 months compared with 10–11 months achieved with PDT or chemotherapy alone.⁴²^,⁴³ These findings suggest a potential synergistic benefit of PDT with systemic agents in advanced disease.

PDT is generally well tolerated. The most common AEs include cholangitis, transient photosensitivity, and, less frequently, liver abscesses. Traditional photosensitizers, such as porfimer sodium, require strict light avoidance for 4–6 weeks. However, newer-generation agents, such as temoporfin, offer shorter photosensitivity periods and improved patient convenience.² All patients should receive antibiotic prophylaxis, particularly those with primary sclerosing cholangitis or other infection risk factors. Common regimens include third-generation cephalosporins or piperacillin-tazobactam.²⁷

Despite its demonstrated clinical benefits, the widespread implementation of PDT remains constrained by its high cost and off-label designation in many healthcare systems.² Broader adoption will require standardized treatment protocols, more cost-effectiveness data, and stronger evidence supporting its integration into multimodal treatment strategies. Although PDT is not currently established as an adjuvant therapy for hilar malignancies, emerging data suggest potential utility as a neoadjuvant modality to enable curative resection in select patients. Currently, its principal role remains palliative, where it has been shown to enhance survival, facilitate biliary decompression, and improve quality of life in patients with unresectable MHBO.

Biliary radiofrequency ablation

Radiofrequency ablation (RFA) is an adjunctive therapy to endobiliary stenting for managing MHBO. This therapy delivers localized thermal energy to induce coagulative necrosis within the malignant tissue, aiming to improve biliary stent patency and potentially prolonging survival. During ERCP, RFA involves advancing a bipolar catheter over a guidewire across the malignant stricture (Fig. 5). Energy is typically delivered for 90–120 seconds, followed by a cool-down period to minimize collateral tissue damage. Ablation depth typically reaches 8–10 mm, depending on catheter specifications. To enhance safety, temperature-controlled catheters have been developed to provide real-time feedback on impedance and tissue temperature, thereby reducing the risk of thermal injury such as perforation. Following ablation, an SEMS or PS is placed to maintain ductal patency, reduce the risk of cholangitis, and prevent early re-occlusion. RFA can be repeated at approximately 3-month intervals; however, this approach requires repeated ERCPs and careful patient selection.²^,⁴⁴^,⁴⁵

Two endobiliary RFA catheters are commonly used in clinical practice: the Habib EndoHPB (Boston Scientific) and the ELRA catheter (STARmed Co.). The Habib EndoHPB is an 8 Fr, 180 cm bipolar catheter featuring two ring electrodes spaced 8 mm apart. The catheter is compatible with standard electrosurgical generators and integrates easily into routine ERCP workflows.⁴⁶ The ELRA catheter is a temperature-controlled bipolar probe available in 7 Fr and 8 Fr diameters, offering ablation lengths of 18 mm and 33 mm. Its real-time thermal monitoring may enhance safety in anatomically complex hilar regions.⁴⁷ Both devices can be used via ERCP or PTBD, with selection typically based on operator preference, device availability, and stricture anatomy. To date, no head-to-head trials have directly compared these devices for the treatment of hilar lesions.

The role of RFA in MHBO has been evaluated in several studies, including RCTs and meta-analyses. The ACG acknowledges that RFA combined with stenting is associated with improved survival in malignant biliary obstruction; however, most studies include mixed cohorts of distal and hilar lesions, and data specific to MHBO remain limited.² In a meta-analysis focused on unresectable perihilar CCA, RFA plus stenting was associated with a median overall survival of 9.5 (95% CI, 6.3–12.6) months compared to 7.0 (95% CI, 5.7–8.2) months for stenting alone (pooled HR for death, 0.65; 95% CI, 0.50–0.84).⁴⁸ Similarly, a case-control study of patients with unresectable Bismuth III/IV CCA reported a mean survival of 342±57 days in the RFA group versus 221±26 days with stenting alone (p=0.046).⁴⁹ Regarding stent patency, broader meta-analyses (not specific to hilar lesions) report a mean extension of 43–50 days with RFA.⁴⁴^,⁴⁵ In the hilar region specifically, one prospective study evaluating RFA for tumor ingrowth after bilateral SEMS placement reported a technical success rate of 93.3% and clinical success in 71.4% of cases.² AEs associated with RFA include abdominal pain, cholangitis, hemobilia, cholecystitis, and pancreatitis, but pooled analyses suggest no significant increase in serious AEs compared with stenting alone.⁵⁰

Overall, biliary RFA is a feasible and promising adjunctive therapy in the palliative management of MHBO. This procedure appears to modestly improve median survival and stent patency, with high technical success rates and an acceptable safety profile. While current evidence supports its use in select patients, further prospective studies focused specifically on hilar lesions are needed to define standardized protocols, long-term outcomes, and the optimal role of RFA within the therapeutic algorithm for MHBO.

ENDOSCOPIC ULTRASOUND-GUIDED BILIARY DRAINAGE

EUS-BD has emerged as an effective alternative to PTBD when conventional ERCP is unsuccessful or anatomically unfeasible in patients with MHBO. Although ERCP remains the first-line approach, failure rates may reach 10% to 15%, particularly in patients with surgically altered anatomy or high-grade hilar strictures. In such cases, EUS-BD enables internal biliary decompression while avoiding the morbidity and quality-of-life limitations associated with external drainage catheters. For hilar obstruction specifically, EUS-guided hepaticogastrostomy (EUS-HGS) is the preferred EUS-BD technique (Fig. 6). In contrast, EUS-guided choledochoduodenostomy (EUS-CDS), which is commonly used for distal biliary strictures, is generally unsuitable for MHBO because of anatomical constraints, as the duodenum does not lie in proximity to the intrahepatic bile ducts.⁵¹^,⁵² Table 2 presents a summary of key studies evaluating EUS-HGS for MHBO, such as technical success, clinical success, AEs, and comparison with PTBD.⁵²^-⁵⁵

The reported technical success rate of EUS-HGS for MHBO ranges from 94% to 98%, with clinical success rates between 80% and 98%. A recent meta-analysis of 70 studies including 3,527 patients reported technical and clinical success rates for EUS-HGS of 98.1% (95% CI, 97.5%–98.7%) for both outcomes. Similarly, another meta-analysis of 33 studies (n=1,644) reported a technical success rate of 97.7% (95% CI, 96.1%–99.0%) and a clinical success rate of 88.1% (95% CI, 84.7%–91.2%). These high success rates underscore the reliability of EUS-HGS for accessing the left intrahepatic biliary system in patients with hilar disease.⁵³^,⁵⁴ AE rates for EUS-HGS range from 12%–15%, with bile leak (2%–2.4%), cholangitis or sepsis (2.8%), and bleeding (2.3%) being the most commonly reported AEs.⁵⁴ Notably, a multicenter randomized phase II trial comparing EUS-HGS with PTBD demonstrated a significantly lower 30-day morbidity rate with EUS-HGS (28.6%) compared with PTBD (62%).⁵³ These findings support the favorable safety profile of EUS-HGS, particularly when performed at high-volume centers by experienced endosonographers. However, dedicated devices for the performance of EUS-HGS are under development and may improve the safety profile of the procedure in the future.

Compared with PTBD, EUS-HGS achieves comparable technical and clinical success while offering several key advantages: lower AE rates, fewer reinterventions, shorter hospital stays, and better patient-reported outcomes. Accordingly, both the ACG and ASGE recommend EUS-BD, primarily EUS-HGS, as the preferred rescue strategy following failed ERCP for hilar obstruction, provided that local expertise is available.²^,⁵⁶^,⁵⁷ Although EUS-CDS demonstrates high success rates in malignant distal obstruction (>95%), this procedure is generally unsuitable for hilar lesions due to the limited access to the intrahepatic ducts and the absence of supporting data in this context.⁵¹^,⁵⁸

Overall, EUS-HGS provides a safe and effective drainage option for patients with MHBO after failed ERCP. With technical and clinical success rates approaching 98% and a significantly lower morbidity burden than PTBD, EUS-HGS is increasingly recognized as a central component of palliative management algorithms for complex hilar obstruction.

SPECIAL POPULATIONS

Certain patient populations pose unique challenges in the management of MHBO. Patients with surgically altered anatomy, such as Roux-en-Y or Billroth II reconstructions, may require balloon-assisted ERCP, PTBD, or EUS-BD due to limited access to the ampulla. EUS-BD, including HGS or hepaticoduodenostomy, is particularly useful in these cases because the procedure provides internal drainage and avoids external catheters, although it requires advanced expertise and may not be available at all centers. Patients with indwelling stents or prior interventions often necessitate specialized techniques, such as stent trimming, cholangioscopy-assisted guidewire passage, or overlapping and parallel stent placement. Covered SEMSs can generally be removed if needed, whereas uncovered SEMSs typically require additional in-situ stenting for reintervention. Institutional resources and operator experience are critical in determining the optimal approach. In smaller centers or resource-limited settings, PS or PTBD may remain the primary drainage option. Additionally, frailty, limited life expectancy, and patient preferences must be carefully considered. In patients with minimal symptoms or advanced disease, the risks of intervention may outweigh potential benefits. Shared decision-making remains essential to ensure that treatment plans align with the patient's goals and overall quality of life.²^,³^,⁵⁹^,⁶⁰

FUTURE DIRECTIONS

Future efforts in the management of MHBO should focus on optimizing stent design, procedural strategies, and adjunctive therapies to improve stent patency, reduce infections, and minimize the need for reintervention, particularly in patients with longer life expectancy. Emerging stent technologies, including anti-reflux SEMS, drug-eluting platforms, and biodegradable stents, are being investigated for their potential to mitigate tumor ingrowth, biofilm formation, and occlusion; however, robust clinical validation in hilar-specific populations remains necessary. Innovations in stent configuration and delivery systems, such as large-cell mesh designs and ultra-slim catheters, have enhanced technical success and facilitated reintervention in complex hilar anatomies, as demonstrated in recent studies evaluating novel SEMS platforms. Adjunctive therapies, including biliary RFA and PDT, show promise in prolonging stent patency and survival. However, current ACG and ASGE guidelines underscore the need for high-quality, hilar-specific prospective trials to better define their roles, particularly in advanced Bismuth type strictures. EUS-BD is increasingly recognized as an alternative to PTBD following failed ERCP and may offer internal drainage with reduced catheter burden in select patients. Nevertheless, its application in MHBO remains investigational and will require further technical refinement, device innovation, and structured training to ensure safe and effective adoption.

CONCLUSIONS

This review summarizes current strategies and evolving evidence in palliative biliary stenting for MHBO, emphasizing guideline-based practices. With improved survival resulting from contemporary oncologic therapies, the stent paradigm has shifted from routine SEMS placement to the use of PS as the preferred initial approach. PSs are preferred for establishing biliary drainage, followed by scheduled exchanges during ongoing cancer-directed therapies. SEMSs should be reserved for patients with a life expectancy of less than 3–6 months or those not planning to undergo further treatment and prefer to avoid elective stent exchanges, recognizing that tumor ingrowth resulting in SEMS obstruction can be very challenging to manage. Recent societal and consensus statements have shifted away from the unilateral versus bilateral framework toward a sectoral approach, recommending decompression of more than 50% of functional liver volume. Endoscopic drainage is generally preferred over percutaneous approaches due to lower rates of AEs, better patient comfort, and improved quality of life. Additionally, endoscopic techniques facilitate internal drainage and easier access for repeat interventions, making them particularly suitable for patients undergoing ongoing systemic therapy. Adjunctive therapies, such as biliary RFA and PDT, may help prolong stent patency, while EUS-HGS is increasingly recognized as the salvage strategy of choice when left-sided drainage cannot be achieved with ERCP. Continued innovation in stent design, procedural techniques, and operator training will be critical to improving outcomes in this challenging clinical setting.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: all authors; Investigation: all authors; Writing–original draft: all authors; Writing–review & editing: all authors; Supervision: VC.

Fig. 1.

Bismuth-Corlette Classification (I–IV) for hilar cholangiocarcinoma.

Fig. 2.

Summary of stent selection considerations in malignant hilar biliary obstruction. SEMS, self-expanding metal stent.

Fig. 3.

Bilateral plastic stent placement for a perihilar biliary stricture in a patient with primary sclerosing cholangitis and Bismuth type IV cholangiocarcinoma. (A) Cholangiogram showing a tight perihilar stricture involving both right and left hepatic ducts. (B) Final cholangiogram demonstrating successful bilateral plastic stent placement with adequate drainage of both hepatic systems.

Fig. 4.

Photodynamic therapy for biliary stricture: endoscopic (A) and anatomical (B) representations.

Fig. 5.

Biliary radiofrequency ablation (RFA) for malignant hilar stricture. (A) Fluoroscopic image showing hilar stricture consistent with cholangiocarcinoma; (B) radiofrequency ablation of the biliary stricture in progress using a biliary RFA probe (inset).

Fig. 6.

Endoscopic ultrasound-guided hepaticogastrostomy. (A) Cholangiogram following endoscopic ultrasound-guided puncture of the intrahepatic duct. (B) Final fluoroscopic view demonstrating placement of a double-pigtail plastic stent extending from the gastric lumen into the intrahepatic duct.

Table 1.

Summary of key studies (2008–2023) comparing plastic stents versus self-expandable metal stents for the management of malignant hilar biliary obstruction

Study	Year	Type	Bismuth type	Method	No. of patients	Technical success (%)	Clinical success (%)	Time to RBO (mo)	Adverse event rate (%)	Median survival (mo)
Perdue et al.¹⁹	2008	Prospective	II–IV	PS vs. MS	28 vs. 34	100 vs. 100	67.9 vs. 91.2	32.1 vs. 11.8	39.3 vs. 11.8	Not reported
Raju et al.²⁰	2011	Retrospective	I–IV	PS vs. MS	52 vs. 48	100 vs. 100	94.2 vs. 95.8	7.7 vs. 8.3	15.4 vs. 8.3	8.2 vs. 9.1
Liberato and Canena²¹	2012	Retrospective	I–IV	UPS vs. UMS	231 vs. 249	88.3 vs. 98.8	84.8 vs. 97.9	4.6 vs. 6.2	20.8 vs. 23.0	10.6 vs. 10.4
Sangchan et al.²²	2012	RCT	II–IV	UPS vs. UMS	54 vs. 54	85.2 vs. 88.3	46.3 vs. 70.4	1.2 vs. 3.4	40.7 vs. 25.9	1.6 vs. 4.1
Mukai et al.²³	2013	RCT	II–IV	UPS vs. UMS	30 vs. 30	100 vs. 100	100 vs. 100	3.7 vs. 11.9	33.3 vs. 20	6.2 vs. 7.5
Xia et al.²⁴	2021	Matched retrospective	II–IV	BPS vs. BMS	96 vs. 96	100 vs. 100	71.9 vs. 99.0	4.8 vs. 9.2	26.0 vs. 7.3	4.1 vs. 7.2
Kanno et al.²⁵	2023	Multicenter RCT	II–IV	BPS vs. BMS	38 vs. 46	100 vs. 96.6	90.0 vs. 88.9	8.2 vs. 11.9	10.5 vs. 15.2	7.1 vs. 7.5
Okuno et al.²⁶	2023	Matched retrospective	II–IV	BPS vs. BMS	38 vs. 38	100 vs. 97	97 vs. 97	5.6 vs. 7.4	5.3 vs. 15.8	7.4 vs. 8.9

RBO, recurrent biliary obstruction; PS, plastic stent; MS, metal stent; UPS, unilateral plastic stent; UMS, unilateral metal stent; RCT, randomized clinical trial; BPS, bilateral plastic stent; BMS, bilateral metal stent.

Table 2.

Summary of recent studies evaluating endoscopic ultrasound-guided hepaticogastrostomy for malignant hilar biliary obstruction

Study	Year	Analysis	Population/indication	Technical success (%)	Clinical success (%)	Adverse event rate (%)	Comparison to PTBD
Binda et al.⁵²	2024	Meta-analysis	Malignant biliary obstruction (16% hilar stenosis)	97.7	88.1	12.0	Not directly compared
Alsakarneh et al.⁵⁴	2024	Meta-analysis	Failed ERCP (malignant/benign, includes hilar)	98.1	98.1	14.9	Not directly compared
Moond et al.⁵⁵	2024	Meta-analysis	EUS-HGS for biliary drainage (mixed, includes hilar)	94.4	88.6	23.8	Not directly compared
Marx et al.⁵³	2022	RCT	Obstructive jaundice (benign/malignant, including perihilar) after failed ERCP	94.3 (EUS-HGS) vs. 100 (PTBD)	80 (EUS-HGS) vs. 66.7 (PTBD)	28.6 (EUS-HGS) vs. 61.9 (PTBD, 30-day morbidity)	EUS-HGS: lower reintervention risk, lower morbidity

PTBD, percutaneous transhepatic biliary drainage; ERCP, endoscopic retrograde cholangiopancreatography; EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; RCT, randomized clinical trial.

REFERENCES

1. Balaban EP, Mangu PB, Khorana AA, et al. Locally advanced, unresectable pancreatic cancer: american society of clinical oncology clinical practice guideline. J Clin Oncol 2016;34:2654–2668.Article PubMed PMC
2. Elmunzer BJ, Maranki JL, Gómez V, et al. ACG clinical guideline: diagnosis and management of biliary strictures. Am J Gastroenterol 2023;118:405–426.Article PubMed
3. Qumseya BJ, Jamil LH, Elmunzer BJ, et al. ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction. Gastrointest Endosc 2021;94:222–234.Article PubMed
4. Angsuwatcharakon P, Kulpatcharapong S, Chuncharunee A, et al. The updated Asia-Pacific consensus statement on the role of endoscopic management in malignant hilar biliary obstruction. Endosc Int Open 2024;12:E1065–E1074.Article PubMed PMC
5. Ruas JN, Mendonça EQ, Lenz L, et al. Correlation between liver volume drainage and clinical success after endoscopic biliary drainage of hilar malignant obstruction. Clinics (Sao Paulo) 2025;80:100540.Article PubMed PMC
6. Vienne A, Hobeika E, Gouya H, et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endosc 2010;72:728–735.Article PubMed
7. Fairchild AH, Hohenwalter EJ, Gipson MG, et al. ACR appropriateness Criteria® radiologic management of biliary obstruction. J Am Coll Radiol 2019;16:S196–S213.Article PubMed
8. Wang Y, Zhao X, She Y, et al. The clinical efficacy and safety of different biliary drainage in malignant obstructive jaundice: a meta-analysis. Front Oncol 2024;14:1370383.Article PubMed PMC
9. Van Eecke E, Degroote H, Vanlander A, et al. Outcome of primary ERCP versus primary PTC for biliary drainage in malignant hilar biliary strictures: a systematic review and meta-analysis. Surg Endosc 2022;36:7160–7170.Article PubMed PMC PDF
10. Bian C, Fang Y, Xia J, et al. Is percutaneous drainage better than endoscopic drainage in the management of patients with malignant obstructive jaundice? A meta-analysis of RCTs. Front Oncol 2023;13:1105728.Article PubMed PMC
11. Pang L, Wu S, Kong J. Comparison of efficacy and safety between endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangial drainage for the treatment of malignant obstructive jaundice: a systematic review and meta-analysis. Digestion 2023;104:85–96.Article PubMed PMC PDF
12. Moll CF, de Moura DTH, Ribeiro IB, et al. Endoscopic Biliary Darinage (EBD) versus Percutaneous Transhepatic Biliary Drainage (PTBD) for biliary drainage in patients with Perihilar Cholangiocarcinoma (PCCA): a systematic review and meta-analysis. Clinics (Sao Paulo) 2023;78:100163.Article PubMed PMC
13. Rizzo A, Ricci AD, Frega G, et al. How to choose between percutaneous transhepatic and endoscopic biliary drainage in malignant obstructive jaundice: an updated systematic review and meta-analysis. In Vivo 2020;34:1701–1714.Article PubMed PMC
14. Komaya K, Ebata T, Yokoyama Y, et al. Verification of the oncologic inferiority of percutaneous biliary drainage to endoscopic drainage: a propensity score matching analysis of resectable perihilar cholangiocarcinoma. Surgery 2017;161:394–404.Article PubMed
15. Inamdar S, Slattery E, Bhalla R, et al. Comparison of adverse events for endoscopic vs percutaneous biliary drainage in the treatment of malignant biliary tract obstruction in an inpatient national cohort. JAMA Oncol 2016;2:112–117.Article PubMed
16. Law R. Top tips for endoscopic biliary stenting for hilar obstruction. Gastrointest Endosc 2023;97:970–973.Article PubMed
17. Devane AM, Annam A, Brody L, et al. Society of interventional radiology quality improvement standards for percutaneous cholecystostomy and percutaneous transhepatic biliary interventions. J Vasc Interv Radiol 2020;31:1849–1856.Article PubMed
18. Wagner HJ, Knyrim K, Vakil N, et al. Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction. A prospective and randomized trial. Endoscopy 1993;25:213–218.Article PubMed
19. Perdue DG, Freeman ML, DiSario JA, et al. Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study. J Clin Gastroenterol 2008;42:1040–1046.PubMed
20. Raju RP, Jaganmohan SR, Ross WA, et al. Optimum palliation of inoperable hilar cholangiocarcinoma: comparative assessment of the efficacy of plastic and self-expanding metal stents. Dig Dis Sci 2011;56:1557–1564.Article PubMed PDF
21. Liberato MJ, Canena JM. Endoscopic stenting for hilar cholangiocarcinoma: efficacy of unilateral and bilateral placement of plastic and metal stents in a retrospective review of 480 patients. BMC Gastroenterol 2012;12:103.Article PubMed PMC PDF
22. Sangchan A, Kongkasame W, Pugkhem A, et al. Efficacy of metal and plastic stents in unresectable complex hilar cholangiocarcinoma: a randomized controlled trial. Gastrointest Endosc 2012;76:93–99.Article PubMed
23. Mukai T, Yasuda I, Nakashima M, et al. Metallic stents are more efficacious than plastic stents in unresectable malignant hilar biliary strictures: a randomized controlled trial. J Hepatobiliary Pancreat Sci 2013;20:214–222.Article PubMed
24. Xia MX, Pan YL, Cai XB, et al. Comparison of endoscopic bilateral metal stent drainage with plastic stents in the palliation of unresectable hilar biliary malignant strictures: Large multicenter study. Dig Endosc 2021;33:179–189.Article PubMed PDF
25. Kanno Y, Ito K, Nakahara K, et al. Suprapapillary placement of plastic versus metal stents for malignant biliary hilar obstructions: a multicenter, randomized trial. Gastrointest Endosc 2023;98:211–221.Article PubMed
26. Okuno M, Iwata K, Iwashita T, et al. Utility of bilateral intraductal plastic stent for malignant hilar biliary obstruction compared with bilateral self-expandable metal stent: a propensity score-matched cohort analysis. Gastrointest Endosc 2023;98:776–786.Article PubMed
27. Bowlus CL, Arrivé L, Bergquist A, et al. AASLD practice guidance on primary sclerosing cholangitis and cholangiocarcinoma. Hepatology 2023;77:659–702.Article PubMed PDF
28. Xia MX, Cai XB, Pan YL, et al. Optimal stent placement strategy for malignant hilar biliary obstruction: a large multicenter parallel study. Gastrointest Endosc 2020;91:1117–1128.Article PubMed
29. Sawas T, Al Halabi S, Parsi MA, et al. Self-expandable metal stents versus plastic stents for malignant biliary obstruction: a meta-analysis. Gastrointest Endosc 2015;82:256–267.Article PubMed
30. Ashat M, Arora S, Klair JS, et al. Bilateral vs unilateral placement of metal stents for inoperable high-grade hilar biliary strictures: a systemic review and meta-analysis. World J Gastroenterol 2019;25:5210–5219.Article PubMed PMC
31. Lee TH, Kim TH, Moon JH, et al. Bilateral versus unilateral placement of metal stents for inoperable high-grade malignant hilar biliary strictures: a multicenter, prospective, randomized study (with video). Gastrointest Endosc 2017;86:817–827.Article PubMed
32. Cheon YK, Lee TY, Lee SM, et al. Longterm outcome of photodynamic therapy compared with biliary stenting alone in patients with advanced hilar cholangiocarcinoma. HPB (Oxford) 2012;14:185–193.Article PubMed PMC
33. Ortner ME, Caca K, Berr F, et al. Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study. Gastroenterology 2003;125:1355–1363.Article PubMed
34. Berr F, Wiedmann M, Tannapfel A, et al. Photodynamic therapy for advanced bile duct cancer: evidence for improved palliation and extended survival. Hepatology 2000;31:291–298.Article PubMed
35. Wagner A, Wiedmann M, Tannapfel A, et al. Neoadjuvant down-sizing of hilar cholangiocarcinoma with photodynamic therapy: long-term outcome of a phase II pilot study. Int J Mol Sci 2015;16:26619–26628.Article PubMed PMC
36. Wiedmann M, Caca K, Berr F, et al. Neoadjuvant photodynamic therapy as a new approach to treating hilar cholangiocarcinoma: a phase II pilot study. Cancer 2003;97:2783–2790.Article PubMed
37. Mohan BP, Chandan S, Khan SR, et al. Photodynamic therapy (PDT), radiofrequency ablation (RFA) with biliary stents in palliative treatment of unresectable extrahepatic cholangiocarcinoma: a systematic review and meta-analysis. J Clin Gastroenterol 2022;56:e153–e160.PubMed
38. Li Z, Jiang X, Xiao H, et al. Long-term results of ERCP- or PTCS-directed photodynamic therapy for unresectable hilar cholangiocarcinoma. Surg Endosc 2021;35:5655–5664.Article PubMed PMC PDF
39. Moole H, Tathireddy H, Dharmapuri S, et al. Success of photodynamic therapy in palliating patients with nonresectable cholangiocarcinoma: a systematic review and meta-analysis. World J Gastroenterol 2017;23:1278–1288.Article PubMed PMC
40. Lee TY, Cheon YK, Shim CS, et al. Photodynamic therapy prolongs metal stent patency in patients with unresectable hilar cholangiocarcinoma. World J Gastroenterol 2012;18:5589–5594.Article PubMed PMC
41. Park DH, Lee SS, Park SE, et al. Randomised phase II trial of photodynamic therapy plus oral fluoropyrimidine, S-1, versus photodynamic therapy alone for unresectable hilar cholangiocarcinoma. Eur J Cancer 2014;50:1259–1268.Article PubMed
42. Gonzalez-Carmona MA, Bolch M, Jansen C, et al. Combined photodynamic therapy with systemic chemotherapy for unresectable cholangiocarcinoma. Aliment Pharmacol Ther 2019;49:437–447.Article PubMed PDF
43. Hong MJ, Cheon YK, Lee EJ, et al. Long-term outcome of photodynamic therapy with systemic chemotherapy compared to photodynamic therapy alone in patients with advanced hilar cholangiocarcinoma. Gut Liver 2014;8:318–323.Article PubMed PMC
44. Sofi AA, Khan MA, Das A, et al. Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc 2018;87:944–951.Article PubMed
45. Hayat U, Ashfaq MZ, Haseeb M, et al. Adjuvant radiofrequency ablation along with stenting versus stenting alone for biliary tree drainage in patients with malignant biliary strictures: a systemic review and meta-analysis. J Clin Gastroenterol 2024;58:297–306.PubMed
46. Dolak W, Schreiber F, Schwaighofer H, et al. Endoscopic radiofrequency ablation for malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications. Surg Endosc 2014;28:854–860.Article PubMed PDF
47. Kang H, Chung MJ, Cho IR, et al. Efficacy and safety of palliative endobiliary radiofrequency ablation using a novel temperature-controlled catheter for malignant biliary stricture: a single-center prospective randomized phase II TRIAL. Surg Endosc 2021;35:63–73.Article PubMed PDF
48. de Jong DM, Fritzsche JA, Audhoe AS, et al. Comparison of intraductal RFA plus stent versus stent-only treatment for unresectable perihilar cholangiocarcinoma-a systematic review and meta-analysis. Cancers (Basel) 2022;14:2079.Article PubMed PMC
49. Bokemeyer A, Matern P, Bettenworth D, et al. Endoscopic radiofrequency ablation prolongs survival of patients with unresectable hilar cholangiocellular carcinoma: a case-control study. Sci Rep 2019;9:13685.Article PubMed PMC PDF
50. Tarar ZI, Farooq U, Gandhi M, et al. Effect of radiofrequency ablation in addition to biliary stent on overall survival and stent patency in malignant biliary obstruction: an updated systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2023;35:646–653.Article PubMed
51. Hara K, Yamao K, Mizuno N, et al. Endoscopic ultrasonography-guided biliary drainage: Who, when, which, and how? World J Gastroenterol 2016;22:1297–1303.Article PubMed PMC
52. Binda C, Dajti E, Giuffrida P, et al. Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy: a meta-regression analysis. Endoscopy 2024;56:694–705.Article PubMed
53. Marx M, Caillol F, Autret A, et al. EUS-guided hepaticogastrostomy in patients with obstructive jaundice after failed or impossible endoscopic retrograde drainage: a multicenter, randomized phase II Study. Endosc Ultrasound 2022;11:495–502.Article PubMed PMC
54. Alsakarneh S, Madi MY, Dahiya DS, et al. Is Endoscopic ultrasound-guided hepaticogastrostomy safe and effective after failed endoscopic retrograde cholangiopancreatography?: a systematic review and meta-analysis. J Clin Med 2024;13:3883.Article PubMed PMC
55. Moond V, Loganathan P, Koyani B, et al. Efficacy and safety of EUS-guided hepatogastrostomy: a systematic review and meta-analysis. Endosc Ultrasound 2024;13:171–182.Article PubMed PMC
56. Sharaiha RZ, Khan MA, Kamal F, et al. Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis. Gastrointest Endosc 2017;85:904–914.Article PubMed
57. Marya NB, Pawa S, Thiruvengadam NR, et al. American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: methodology and review of evidence. Gastrointest Endosc 2024;100:e79–e135.Article PubMed
58. Jacques J, Privat J, Pinard F, et al. EUS-guided choledochoduodenostomy by use of electrocautery-enhanced lumen-apposing metal stents: a French multicenter study after implementation of the technique (with video). Gastrointest Endosc 2020;92:134–141.Article PubMed
59. Kongkam P, Tasneem AA, Rerknimitr R. Combination of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography-guided biliary drainage in malignant hilar biliary obstruction. Dig Endosc 2019;31 Suppl 1:50–54.Article PubMed PDF
60. Eisenberg I, Gaidhane M, Kahaleh M, et al. Drainage approach for malignant biliary obstruction: a changing paradigm. J Clin Gastroenterol 2023;57:546–552.PubMed

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Palliative endoscopic biliary drainage for malignant hilar biliary obstruction

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Palliative endoscopic biliary drainage for malignant hilar biliary obstruction

Fig. 1. Bismuth-Corlette Classification (I–IV) for hilar cholangiocarcinoma.

Fig. 2. Summary of stent selection considerations in malignant hilar biliary obstruction. SEMS, self-expanding metal stent.

Fig. 3. Bilateral plastic stent placement for a perihilar biliary stricture in a patient with primary sclerosing cholangitis and Bismuth type IV cholangiocarcinoma. (A) Cholangiogram showing a tight perihilar stricture involving both right and left hepatic ducts. (B) Final cholangiogram demonstrating successful bilateral plastic stent placement with adequate drainage of both hepatic systems.

Fig. 4. Photodynamic therapy for biliary stricture: endoscopic (A) and anatomical (B) representations.

Fig. 5. Biliary radiofrequency ablation (RFA) for malignant hilar stricture. (A) Fluoroscopic image showing hilar stricture consistent with cholangiocarcinoma; (B) radiofrequency ablation of the biliary stricture in progress using a biliary RFA probe (inset).

Fig. 6. Endoscopic ultrasound-guided hepaticogastrostomy. (A) Cholangiogram following endoscopic ultrasound-guided puncture of the intrahepatic duct. (B) Final fluoroscopic view demonstrating placement of a double-pigtail plastic stent extending from the gastric lumen into the intrahepatic duct.

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Fig. 6.

Palliative endoscopic biliary drainage for malignant hilar biliary obstruction

Study	Year	Type	Bismuth type	Method	No. of patients	Technical success (%)	Clinical success (%)	Time to RBO (mo)	Adverse event rate (%)	Median survival (mo)
Perdue et al.19	2008	Prospective	II–IV	PS vs. MS	28 vs. 34	100 vs. 100	67.9 vs. 91.2	32.1 vs. 11.8	39.3 vs. 11.8	Not reported
Raju et al.20	2011	Retrospective	I–IV	PS vs. MS	52 vs. 48	100 vs. 100	94.2 vs. 95.8	7.7 vs. 8.3	15.4 vs. 8.3	8.2 vs. 9.1
Liberato and Canena21	2012	Retrospective	I–IV	UPS vs. UMS	231 vs. 249	88.3 vs. 98.8	84.8 vs. 97.9	4.6 vs. 6.2	20.8 vs. 23.0	10.6 vs. 10.4
Sangchan et al.22	2012	RCT	II–IV	UPS vs. UMS	54 vs. 54	85.2 vs. 88.3	46.3 vs. 70.4	1.2 vs. 3.4	40.7 vs. 25.9	1.6 vs. 4.1
Mukai et al.23	2013	RCT	II–IV	UPS vs. UMS	30 vs. 30	100 vs. 100	100 vs. 100	3.7 vs. 11.9	33.3 vs. 20	6.2 vs. 7.5
Xia et al.24	2021	Matched retrospective	II–IV	BPS vs. BMS	96 vs. 96	100 vs. 100	71.9 vs. 99.0	4.8 vs. 9.2	26.0 vs. 7.3	4.1 vs. 7.2
Kanno et al.25	2023	Multicenter RCT	II–IV	BPS vs. BMS	38 vs. 46	100 vs. 96.6	90.0 vs. 88.9	8.2 vs. 11.9	10.5 vs. 15.2	7.1 vs. 7.5
Okuno et al.26	2023	Matched retrospective	II–IV	BPS vs. BMS	38 vs. 38	100 vs. 97	97 vs. 97	5.6 vs. 7.4	5.3 vs. 15.8	7.4 vs. 8.9

Study	Year	Analysis	Population/indication	Technical success (%)	Clinical success (%)	Adverse event rate (%)	Comparison to PTBD
Binda et al.52	2024	Meta-analysis	Malignant biliary obstruction (16% hilar stenosis)	97.7	88.1	12.0	Not directly compared
Alsakarneh et al.54	2024	Meta-analysis	Failed ERCP (malignant/benign, includes hilar)	98.1	98.1	14.9	Not directly compared
Moond et al.55	2024	Meta-analysis	EUS-HGS for biliary drainage (mixed, includes hilar)	94.4	88.6	23.8	Not directly compared
Marx et al.53	2022	RCT	Obstructive jaundice (benign/malignant, including perihilar) after failed ERCP	94.3 (EUS-HGS) vs. 100 (PTBD)	80 (EUS-HGS) vs. 66.7 (PTBD)	28.6 (EUS-HGS) vs. 61.9 (PTBD, 30-day morbidity)	EUS-HGS: lower reintervention risk, lower morbidity

Table 1. Summary of key studies (2008–2023) comparing plastic stents versus self-expandable metal stents for the management of malignant hilar biliary obstruction

Table 2. Summary of recent studies evaluating endoscopic ultrasound-guided hepaticogastrostomy for malignant hilar biliary obstruction

PTBD, percutaneous transhepatic biliary drainage; ERCP, endoscopic retrograde cholangiopancreatography; EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; RCT, randomized clinical trial.