Introduction

Hilar cholangiocarcinoma patients often require biliary drainage, but objective tools for assessing the effectiveness of endoscopic biliary drainage are unsatisfactory. Studies have shown that biliary obstruction can reduce hepatic blood flow.

Aims & Methods

The aim of this study was to analyze changes in portal vein flow after endoscopic biliary drainage and evaluate the correlation between portal vein flow and liver function.
​A prospective study enrolled 14 patients who underwent endoscopic stenting for hilar cholangiocarcinoma between September 2021 and June 2022. Portal vein velocity (Vmax) by Doppler ultrasonography and bilirubin level were assessed on all patients before and on the 1st, 3rd, and 14th days after endoscopic drainage. The patients were divided into two groups based on the success of drainage, with 11 patients in Group A (successful) and 3 in Group B (unsuccessful).

Results

​The mean Vmax was 14.3 ± 2.5 cm/s before endoscopic drainage and 16.4 ± 3.3 cm/s, 18.0 ± 3.6 cm/s, and 20.8 ± 5.5 cm/s on the 1st, 3rd, and 14th day after drainage, respectively. The Vmax was significantly higher on each day following drainage compared to before (p<0.001). The rate of increase in Vmax was significantly higher in Group A than Group B on the 14th day (1.6 ± 0.48 vs 1.1 ± 0.13, P=0.03). The rate of increased Vmax correlated significantly with the rate of decreased serum bilirubin levels (r² = 0.407, P < 0.001).

Conclusion

​Successful endoscopic biliary drainage in hilar cholangiocarcinoma significantly increased portal vein velocity (Vmax). Vmax assessment by Doppler ultrasonography may be a useful tool for evaluating the effectiveness of endoscopic biliary drainage in malignant hilar biliary obstruction.

Introduction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a minimally invasive and promising alternative to percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in managing malignant biliary obstruction. Different techniques are available such as choledocoduodenostomy (CDS), gallbladder drainage (GBD) and hepaticogastrostomy HGS). All have been shown to be safe and effective techniques, but which is the most suitable and effective approach is still unknown.

Aims & Methods

We aim to compare the three techniques available in terms of technical success and clinical success, and to assess the adverse events related to the different procedures. Single center retrospective analysis of all consecutive cases of CDS, GBD and HGS acceding to the Therapeutic Endoscopy Unit of Fondazione Policlinico Universitario Campus Bio-Medico of Rome. Data about patients and procedures were collected. Technical success was defined as successful biliary drainage with stent placement. Clinical success was defined as a decrease in total bilirubin level by ⩾30% within 7 days of EUS-BD.

Results

From April 2016 to December 2024 101 patients were included (47.5% male, mean age 74.6 years old), all with malignant biliary obstruction. 52,5% of the subjects (53/101) underwent EUS-CDS, 22,7 % (23/101) underwent EUS-GBD and 24,75% (25/101) underwent EUS-HGS. In 35/101 (34,65%) duodenal stenosis was observed. A total of 7 patients had altered anatomy. The mean procedure time was 26 ± 15,7 minutes. Overall technical success was 93%, 48/53 (90,5%) in the CDS group, 23/23 (100%) in the GBD group and 23/25 (92%) in the HGS group. Overall clinical success was achieved in 57/79 (72%), 29/38 (76,3%) in the CDS group, 12/20 (60%) in the GBD group and 16/21 (76,1%) in the HGS group. When considering a reduction in bilirubin level ⩾50%, the overall clinical success was lower (55%). Adverse events occurred in 6/101 (5,9%) of the patients, 3/53 (5,6%) in the CDS group, 0/23 in the GBD group and 3/25 (12%) in the HGS group. There was no difference in terms of sex, age, altered anatomy, presence of duodenal stenosis and the EUS technique performed. The mean time of the procedure was higher in the HGS group, with a difference statistically significant (CDS=22,87±14,78 min, GBD=26±15,73 min, HGS=41±16,09 min, p=0,005). No difference was observed in terms of technical and clinical success, and adverse events between the three procedures. However, if the reduction in bilirubin level ⩾50% cut-off was used, the HGS was the procedure with the highest rate of clinical success (CDS 59,5% vs GBD 25% vs HGS 76%, p=0,003).

Conclusion

EUS-BD is a safe procedure with high technical and clinical success rate and it s a valid alternative for managing malignant biliary obstruction in high volumes centers. No differences are described between the three approaches. However HGS seems to reduce bilirubin levels more quickly, with longer procedure time.

Introduction

Malignant biliary obstruction (MBO) caused by non-hepatobiliary-pancreatic (non-HBP) malignancies is a rare and underexplored indication for endoscopic retrograde cholangiopancreatography (ERCP). These cases often present a clinical dilemma: while ERCP offers a minimally invasive option, its utility remains uncertain in patients with poor prognosis and advanced disease.

Aims & Methods

We aimed to evaluate the effectiveness of ERCP-guided biliary drainage in this context and identify baseline predictors of clinical failure to help refine patient selection.
We conducted a retrospective analysis of all patients who underwent ERCP for malignant biliary obstruction of non-HBP origin between March 2018 and February 2025. Patients lacking essential clinical or follow-up data were excluded. Technical success was defined as adequate stent placement; clinical success as a ≥50% reduction in bilirubin or resolution of cholangitis within 2 weeks. The predictive role of bilirubin level, stricture location, serum albumin, and ECOG performance status was assessed. A ROC analysis evaluated the discriminative ability of pre-drainage bilirubin.

Results

Forty-eight patients were included (mean age: 55.6 years; 56% women). The most common primary cancers were colorectal (31%, n=15), gastric (18%, n=9), breast (14%, n=7), lung (10%, n=5), and ovarian (8%, n=4). Hilar strictures were observed in 54% (n=26) and mid-to-distal strictures in 46% (n=22). All procedures were performed using plastic stents. In most cases involving hilar strictures, long stents (e.g., 7 Fr / 12–15 cm) were used, and a single biliary sector—usually the most dilated or invaded—was preferentially drained. Technical success was achieved in 85.4% of cases. Clinical success occurred in 54.1% of patients, while early mortality (≤30 days) reached 10.4%, exclusively among individuals with ECOG status 4 and serum albumin <2.8 g/dL. Hilar strictures and total bilirubin levels >200 mg/L were significantly associated with lower clinical success rates (38% vs 65%, p=0.03 and 33% vs 62%, p=0.04, respectively). ROC analysis showed an AUC of 0.72 for bilirubin in predicting failure. Technical failures (14.6%) were mainly due to anatomical distortion or papillary inaccessibility.

Conclusion

Endoscopic biliary drainage in this population is technically achievable but offers limited clinical benefit, especially in cases with hilar involvement, severe hyperbilirubinemia, or poor overall condition. These findings emphasize the importance of using simple, baseline clinical indicators to guide treatment decisions, avoid unnecessary interventions, and adapt care strategies to the realities of resource-limited settings.

Disclosure

I have no conflict of interest.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is an effective therapeutic option for biliopancreatic cancers, which generally have a good prognosis. However, endoscopic drainage remains a challenge for endoscopists. The aim of our study was to report the outcomes of endoscopic biliary drainage in biliopancreatic tumors and to analyze the factors associated with its success or failure.

Aims & Methods

This was a retrospective, descriptive, comparative, and analytical single-center study conducted in a gastroenterology department over a 5-year period (2019–2024). It included patients with biliopancreatic tumors who underwent ERCP for biliary drainage. Data were collected from medical records and patient follow-up. Factors associated with overall success of endoscopic biliary drainage were analyzed using univariate and multivariate binary logistic regression models.

Results

A total of 206 patients were included. The mean age at diagnosis was 63.2 ± 11.8 years. The female-to-male ratio was 1. Smoking was reported in 31 (15%) patients, alcohol consumption in 17 (8.2%), and a history of biliary surgery in 11 (5.8%).
Pancreatic tumors accounted for 116 (58%) cases, cholangiocarcinomas for 68 (34%), and ampullary tumors for 16 (8%).
Cholestatic jaundice was present in 170 (82.5%) patients, general health deterioration in 133 (64.56%), biliary colic in 48 (23.3%), and pancreatic-type pain in 50 (24.2%). The median bilirubin level was 225 [131–279] mg/L, with 95 patients (46.1%) having levels above 150 mg/L.
During the endoscopic procedure, an abnormal appearance or position of the papilla was noted in 13 (6.3%) patients. A precut or Burdick technique was used in 29 (14%) cases. The double-guidewire technique was used in 33 (16%) patients. Cholangiography showed distal bile duct stenosis in 170 (82.5%) cases. A stent was placed in 168 (81.5%) patients: 120 (58.2%) had uncovered metal stents, 40 (19.4%) had plastic stents, and 8 (3.8%) had covered metal stents.
The overall success rate of biliary drainage was 192 (93.2%).
In univariate analysis, factors associated with drainage failure were the presence of cholangitis (OR = 3.35, 95%CI [1.62–6.9], p = 0.001), bilirubin level >150 mg µmol/L (OR = 3.88, 95%CI [1.6–9.39], p = 0.003), and abnormal papilla appearance or position (OR = 8.73, 95%CI [4.86–32.22], p < 0.001). In contrast, distal bile duct stenosis was associated with successful drainage (OR = 0.56, 95%CI [0.42–0.17], p = 0.045).
In multivariate analysis, after adjusting for the studied variables, predictors of drainage failure were a bilirubin level >150 mg/L (OR = 3.13, 95%CI [2.28–23.15], p = 0.01), and abnormal papilla appearance or position (OR = 4.21, 95%CI [3.18–14.23], p = 0.002). Conversely, predictors of successful drainage included the presence of distal bile duct stenosis (OR = 0.3, 95%CI [0.09–1.03], p = 0.05), and the use of a precut or Burdick technique (OR = 0.44, 95%CI [0.03–0.7], p = 0.047).

Conclusion

Despite the emergence of new techniques, ERCP remains the most commonly used method for biliary drainage in biliopancreatic tumors. Our study identified two main factors predicting failure: a bilirubin level above 150 mg/L and an abnormal papilla. On the other hand, factors associated with success were the presence of distal bile duct stenosis and the use of a precut or Burdick technique.

Introduction

Endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) is primarily used for biliary drainage in patients with malignant distal biliary obstruction. A recent meta-analysis reported a reintervention rate of 15.8% with EUS-CDS. However, studies analyzing the factors associated with reintervention on follow-up after EUS-CDS are limited.

Aims & Methods

The study aimed to analyze the incidence and predictors of reintervention in patients with malignant biliary obstruction undergoing EUS-CDS. The present study is a retrospective analysis of data from eight tertiary care centers in India from January 2022 to January 2024. Patients aged 18-70 years with malignant distal biliary obstruction undergoing EUS-CDS, with a follow-up duration of more than eight weeks, were included. The study's primary outcome was reintervention, which was required in patients with failure of jaundice to improve due to stent migration or stent blockage during the follow‑up, presenting as the worsening of jaundice, with or without cholangitis. The secondary outcomes included clinical success and adverse events. Multivariate analysis using the logistic regression model was used to identify the independent predictors of reintervention.

Results

A total of 140 patients underwent EUS-CDS, out of which 134 patients completed the 8-week follow-up. The median age of the patients was 54.5 (range: 22-90) years, with 53% (71/134) being male. The most common indication for EUS-CDS was inaccessible papilla (59/134, 44.0%), followed by failed cannulation (57/134, 42.5%). The technical success rate was 97.8% (131/134), with placement of self-expanding metal stent (SEMS) in 86.6% (116/134) and lumen-apposing metal stent in 11.2% (15/134). Coaxial double pigtail plastic stent was placed in 19.4% (26/134) cases. Periprocedural adverse events (AE) were seen in 6% (8/134) cases, with severe AE in 0.7% (1/134) cases. Clinical success was achieved in 93.9% (123/131) of the cases with successful stent placement. Over a median follow-up of 20 weeks, reintervention was required in 8.4% of the cases after a median interval of 11 weeks. All patients requiring reintervention could be managed successfully with endoscopic or percutaneous techniques. On multivariate analysis (Table 1), cholangitis at presentation [Odd ratio (OR) 6.26, 95% confidence interval (CI) 1.03-38.09; p =.046] and the absence of coaxial stent with concomitant duodenal stent (OR 7.41, 95% CI: 1.44-38.05; p=.016) were independent predictors of reintervention in the overall cohort. On subgroup analysis of patients undergoing EUS-CDS with SEMS, the absence of coaxial stent with concomitant duodenal stent (OR 10.15, 95% CI: 1.80-57.29; p=.009) was an independent predictor of reintervention.

Conclusion

Reintervention on follow-up after EUS-CDS is required in around 8.4% of cases, with all cases being managed successfully. The absence of coaxial stent with concomitant duodenal stent was an independent predictor of reintervention in the overall cohort as well as in those undergoing EUS-CDS with SEMS.

Introduction

Malignant biliary obstruction is the cause of numerous complications affecting nutritional status. Biliary drainage with stenting is the recommended palliative treatment for these patients. This study assesses the impact of biliary drainage on nutritional status by comparing patients before and after the procedure.

Aims & Methods

The aim of this study was to evaluate, through a retrospective analysis, the variation in patients nutritional status before and after biliary drainage wether in perihilar or periampullary strictures.
We studied 200 patients with malignant biliary stenosis who underwent endoscopic biliary drainage. Demographic, anthropometric and clinical data were collected before and after drainage in two stages (1 month and 3 months). Statistical analysis was performed using SPSS26 software.

Results

The results showed a significant increase in mean weight, reaching 59.27kg after 3 months (p<0.05). Mean BMI also increased significantly, (20.39kg/m² after 3 months (p<0.05)). NRI (Nutritional risk index) decreased significantly after drainage. 35.17% still had severe undernutrition after 3 months (p<0.05). Mean ALB (Albumin) increased significantly, (34.52g/l after 3 months (p<0.05)). Mean TB (Total Bilirubin) also decreased significantly, (15.03mg/l after 3 months (p<0.05)). However, the decrease in CRP was not statistically significant. The WHO performance score showed significant improvement, with 25% of patients presenting with Stage 0 after 3 months. Pruritus and jaundice were absent in 100% of patients after 3 months, and vomiting absent in 90% of patients after 3 months (p<0.05). When comparing the perihilar and periampullary stenosis groups, no significant differences were observed for any of the parameters studied.

Conclusion

The study suggest that endoscopic biliary drainage significantly improves the nutritional and clinical status of patients with malignant biliary strictures, independently of the location of the obstruction.

Disclosure

No conflict of interest.

Introduction

Stent placement by endoscopic retrograde cholangiopancreatography (ERCP) is one of the preferred methods for biliary drainage in unresectable malignant biliary obstruction. Nevertheless, clinical success of palliative drainage is not easy to predict, especially at the time of ERCP.

Aims & Methods

We conducted a multicentre retrospective cohort study in 3 centres in Portugal, involving patients with unresectable malignant biliary obstruction (UMBO) submitted to palliative ERCP-guided biliary stenting between 2015 and 2022. This study aimed to evaluate clinical success of biliary drainage in our population, as well as to evaluate the performance of two recently developed and internally validated risk scores for predicting successful biliary drainage after ERCP-guided endobiliary stenting in UMBO, created by the group of Pausawasdi N. et al. This group developed a first score for predicting early clinical success of biliary drainage (decrease ≥50% in total bilirubin (TB) levels within 2 weeks after stenting), using as variables the presence/absence of extrahepatic biliary obstruction, peritoneal carcinomatosis, the type of biliary stent (plastic or metallic) and pre-endoscopic alkaline phosphatase level. The second score was developed to predict complete clinical success of biliary drainage (normalization of TB levels within 6 weeks after stenting) including pre-endoscopic TB levels, presence/absence of extrahepatic biliary obstruction and type of stent as variables. We included 217 patients for this study. However, due to the limitations of a retrospective analysis, we could not evaluate the performance of these scores for all the patients of our cohort. Statistical analysis was performed using SPSS v.29.

Results

In our cohort, a decrease in total bilirubin (TB) levels ≥50% within 2 weeks after biliary stenting was reached in 81.9%(N=113) of the patients of a subpopulation of 138 patients in which these TB levels were available. TB normalization in 6 weeks after stenting occurred in 55%(N=72) of the cases from a subpopulation of 131 patients in which this TB level was measured. In our population, the predictive scores for early and complete clinical success had an AUROC of 0.597 (95% CI, 0.471-0.723; p = 0.13) and of 0.737 (95% CI, 0.650-0.825; p <0.001), respectively.

Conclusion

In our cohort, the predictive score for complete clinical success of biliary stenting in UMBO (at 6 weeks) had a good accuracy (AUROC 0.74), similar to the AUROC reported by this study group (AUROC 0.76 in the validation cohort). The main advantage of this score relies on the fact that it can be applied before ERCP, since its variables can all be determined pre-endoscopically or, at the most, by the time of ERCP (type of stent), possibly allowing the definition of a better strategy for the management and follow-up of these patients.

References

Pausawasdi, N., Termsinsuk, P., Charatcharoenwitthaya, P., Limsrivilai, J., & Kaosombatwattana, U. (2022). Development and validation of a risk score for predicting clinical success after endobiliary stenting for malignant biliary obstruction. PloS one, 17(8), e0272918. https://doi.org/10.1371/journal.pone.0272918