Endoscopic treatment of malignant hilar biliary obstruction: A retrospective cohort study.

BACKGROUND: Endoscopic biliary drainage for malignant hilar biliary obstruction (MHBO) remains a highly complex endoscopic retrograde cholangiopancreatography (ERCP) procedure. Each case requires an individualized approach, with outcomes influenced by the expertise of the medical center and access to advanced endoscopic tools. AIM: To compare different stent types and drainage strategies, including the use of adjunctive therapies, in patients with MHBO treated endoscopically. METHODS: We retrospectively analyzed 164 patients with MHBO (Bismuth types 3-4) who underwent exclusive endoscopic drainage. Patients were grouped by stent type-uncovered self-expandable metal stents (UCSEMS), bilateral plastic stents, or a mixed approach (fully covered self-expandable metal stents + plastic)-as well as by drainage strategy (unilateral/bilateral) and use of radiofrequency ablation (RFA) or chemotherapy. RESULTS: Patients receiving UCSEMS had significantly longer overall survival compared to those with plastic stents or the mixed approach (P < 0.0001). Mean stent occlusion times were 80 days (bilateral plastic), 84.4 days (mixed approach), and 122.5 days (UCSEMS; P < 0.0001). The mean number of ERCP reinterventions was highest in the UCSEMS group (5.4) compared to bilateral plastic (2.5) and mixed approach group (4.5; P < 0.0001). Patients who received RFA or chemotherapy had significantly longer survival (P < 0.0001). CONCLUSION: Bilateral UCSEMS stenting appears most effective for palliative treatment of MHBO. Adjunctive use of RFA and chemotherapy may further enhance survival, supporting a personalized, multidisciplinary approach.