Post written by Bing Hu, MD, PhD, from the Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Yangpu District, and the Department of Gastroenterology, Third Affiliated Hospital, Second Military Medical University, Jiading District, Shanghai, China.

We compared, for the first time, 4 major stenting modalities simultaneously to determine an optimal strategy for the palliation of malignant hilar biliary obstruction (MHBO) unsuitable for surgery. Endoscopic management of MHBO remains extremely challenging without universal consensus. Our results will help to develop evidence-based guidelines in the future.

From 4 tertiary centers, 633 inoperable MHBO patients who received successfully endoscopic stenting were identified and classified into 4 groups: bilateral metal stent (BMS), unilateral metal stent (UMS), bilateral plastic stent (BPS), and unilateral plastic stent (UPS) placement. After statistical matching to control potential confounders, we found that patients in the BMS group had the highest clinical success rate, the lowest incidence of cholangitis, the least numbers of re-interventions, and the longest stent patency and survival durations. The patients in the UMS group were inferior to those in BMS group but superior to those using plastic stents. So, we recommended that if technically possible, the priority should be given to dual metal stent, followed by single metal stent placement. Our findings may aid in the clinical decision-making process and allow physicians to offer the most suitable treatment for this complex patient population.

Although a change in strategy for biliary drainage can improve survival in MHBO, the median OS was only 2.7-7.1 months with stenting alone in this study. Some additional therapies, such radiofrequency ablation or photodynamic therapy, deserve more studies to further improve the survival benefits in this patient population.

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