Biliary drainage for unresectable malignant hilar biliary obstruction (MHBO) can be technically challenging; therefore, there is a requirement for new treatment methods. This study evaluated the efficacy and safety of a novel bilateral drainage method-endoscopic ultrasound-guided hepaticoduodenostomy plus hepaticogastrostomy (EUS-HDGS)-which combines EUS-guided hepaticoduodenostomy (EUS-HDS) and hepaticogastrostomy (EUS-HGS).

From 2018 to 2024, we reviewed eight cases of EUS-HDGS from 749 EUS procedures. Both EUS-HDS and EUS-HGS were performed simultaneously. The study outcomes were technical success, clinical success (reduced bilirubin levels or improved cholangitis within 14 days), and adverse events.

Technical success was achieved in 87.5% cases (7/8), whereas clinical success was observed in 75.0% (6/8). Mild peritonitis occurred in 25% of patients (2/8) and 75.0% of patients (6/8) experienced recurrent biliary obstruction, with successful reintervention achieved in all cases. Median stent patency period was 90 days (95% confidence interval: 47.0-133).

EUS-HDGS is a safe and effective drainage method for treating refractory MHBO and has potential as a viable treatment option.

Perihilar cholangiocarcinoma (PHCC) is an aggressive biliary malignancy originating from the epithelial cells of the bile duct, typically located in the extrahepatic biliary tree, proximal to the cystic duct. PHCC often presents with a rapid onset of jaundice. While radical surgical resection remains the only curative treatment, only a minority of patients are eligible due to early metastasis and challenges associated with preoperative evaluations. Comprehensive treatments, including chemotherapy, radiotherapy, targeted therapy, and immunotherapy, are crucial for managing PHCC. However, in advanced stages, complications such as cholestatic liver injury, malnutrition, and biliary infections pose significant obstacles to these treatments. Therefore, biliary drainage (BD) is essential in the management of PHCC. In addition to external drainage methods like percutaneous transhepatic biliary drainage (PTBD), endoscopic biliary drainage (EBD), particularly endoscopic retrograde cholangiopancreatography (ERCP), offer an effective option for internal drainage, which is more physiologically compatible and better tolerated. Furthermore, the integration of various endoscopic techniques has expanded the management of PHCC beyond mere drainage. Techniques such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and endoscopic ultrasound (EUS) based methods present new therapeutic avenues, albeit with variable results. This review aims to summarize current advancements and ongoing debates in the field of endoscopic treatment for unresectable PHCC.

Although various self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction (MHBO) have been introduced, the optimal SEMS for MHBO has not yet been established.

This study aimed to evaluate outcomes of the transpapillary placement of an uncovered laser-cut SEMS with an ultra-thin delivery sheath (YABUSAME) for MHBO.

This multicenter, prospective study was conducted in 11 hospitals for 10 months (from March 2022 to December 2022). The primary outcome was the stent patency rate at 6 months. Key secondary outcomes were the technical success rate, clinical success rate, time to recurrent biliary obstruction (RBO), overall survival (OS), and adverse events.

Of 45 enrolled patients, 43 patients underwent biliary drainage, including 42 patients who underwent YABUSAME placement; 66.7% of patients received chemotherapy, and 60% had previously undergone biliary drainage. Drainage methods were partial stent-in-stent, side-by-side, and unilateral in 65.1%, 7.0%, and 27.9% of patients, respectively. Technical and clinical success rates were 93.2% (41/45) and 79.1% (34/45), respectively. The incidence rate of early postprocedural adverse events was 2.2%. The stent patency rate at 6 months was 55.3%. The median time to RBO was 231 days. The median OS was 125 days.

This study showed that the primary outcome, the 6-month stent patency rate, exceeded the expected rate of 55%, which indicates the efficacy of YABUSAME placement for MHBO.

A thorough understanding of normal biliary anatomy, common variants, and surgically altered anatomy is essential for the success of biliary interventions. Variations in biliary anatomy are seen in up to 40% of patients and frequently influence procedural planning and outcomes. This review highlights classical biliary anatomy, its common variations, and the challenges posed by surgical modifications, such as those encountered after cholecystectomy, liver resection, or biliary reconstructions. Case-based examples are used to explore the implications of these variations and modifications on interventional approaches, including the management of bile leaks, strictures, and complex obstructions. Strategies incorporating advanced imaging and procedural techniques, such as rendezvous interventions, are discussed to address complications and optimize outcomes. This article provides a practical framework for interventional radiologists to navigate challenging biliary cases with confidence and precision.

Percutaneous transhepatic bile duct stent insertion is a useful alternative to the endoscopic approach for malignant biliary strictures. This study retrospectively reviewed the cases of percutaneous metallic stent insertion at our institution to evaluate its safety and usefulness.

The study included cases of percutaneous bile duct stent insertion performed between April 2016 and August 2024. All patients included those with malignant biliary obstruction and those in whom an endoscopic approach was first attempted but could not reach or cannulate the papilla of Vater. Two procedures were used: a two-stage procedure, in which a drain was inserted to create an external or internal fistula, followed by stent insertion, and a one-stage procedure, in which the stent was inserted at the same time as the approach to the bile duct. The causes of biliary strictures and complications were examined.

The study included 14 cases: seven patients had pancreatic head cancer, including biliary tract cancer (n = 4) and postoperative gastric cancer (n = 3); three patients who underwent a one-stage insertion. The number of inserted stents tended to increase in patients with postoperative cholangiocarcinoma recurrence. No complication occurred in any patient. One patient had severe cholangitis, eight had moderate cholangitis, and four had mild cholangitis; two patients who underwent one-stage procedures had moderate cholangitis and one had mild cholangitis. In cases of two-stage expandable metal stent (EMS) insertion, the average time from initial drainage to EMS insertion was 10.5 days (4-25).

The stent can be safely inserted in a one-stage procedure without compromising the patient's quality of life. Therefore, one-stage insertion of EMS for malignant biliary stricture may be performed aggressively unless the patient has severe cholangitis.

Although long self-expandable metal stent (SEMS) with a sufficient intragastric portion is typically preferred for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), this design can complicate endoscopic re-intervention for recurrent biliary obstruction (RBO). We evaluated the efficacy and safety of endoscopic re-intervention for RBO through the stent after EUS-HGS using a novel partially covered SEMS with an anchoring flange.

The partially covered SEMS was designed with a intrahepatic uncovered portion measuring 1.5 cm in length and a resilient fold-back wide distal anchoring flange with a 2.0 cm diameter. Re-interventions were performed through the stent lumen while the stent was in situ. The primary outcomes were technical and clinical success, and secondary outcomes were procedure time, adverse events, and the median time to RBO after re-intervention.

In total, 35 re-interventions were performed in 19 patients. Re-intervention was successfully conducted in 97.1% (34/35) of cases via the intragastric end of the stent in a retroflexed position. Technical and clinical success were 94.3% (33/35) and 88.6% (31/35). Re-intervention methods included stent cleaning (18.2%), additional HGS stent placement (33.3%), and antegrade stent placement (48.5%). Mild cholangitis occurred in 5.7% (2/35) of patients and was managed conservatively. The median time to RBO after re-intervention was 148 days.

Endoscopic re-interventions can be effectively and safely performed through the lumen of the novel partially covered SEMS with an anchoring flange.

The goal of this study was to compare the advantages of long slim metal stents (LSMSs) versus conventional metal stents in bilateral endoscopic side-by-side (SBS) deployment for malignant hilar biliary obstruction (MHBO).

A total of 140 consecutive patients with MHBO treated by endoscopic bilateral SBS deployment at a high-volume tertiary referral center were analyzed retrospectively; this included 50 patients in the LSMS group and the other 90 patients in the conventional SBS group as control. Propensity score matching at a 1:2 ratio was used to reduce selection bias. The primary outcome was stent patency.

After propensity score matching, no significant difference was observed in stent patency (267 vs 268 days; P = .923) or overall survival (225 vs 211 days; P = .883) between the 2 groups. The technical success rate was 100% in both groups, and the clinical success rate was 91.1% in the LSMS group and 92.9% in the control group (P = .735). Early and late adverse events were similar (24.4% vs 34.3%, P = .423; 42.2% vs 38.6%, P = .697); the procedure time and bilateral metal stenting time in the LSMS group were significantly shorter (41.0 minutes vs 57.5 minutes, P = .000; 19.0 minutes vs 28.5 minutes, P = .000). The success rate of endoscopic bilateral revisionary stent insertion in the LSMS group was also higher (100% vs 33.3%; P = .000).

Bilateral LSMS placement is a viable option for patients with MHBO. It includes advantages of less operative difficulty and easier future re-intervention over conventional SBS stenting.

Background: Biliary tract cancers (BTCs), including gallbladder and bile duct cancers, have a poor prognosis. Recent advances in chemotherapy, such as using targeted drugs for specific gene mutations, have improved outcomes. Gemcitabine plus cisplatin chemotherapy has been the standard of care for the primary treatment of BTCs, but secondary treatment had not been established until recently. In recent years, durvalumab plus gemcitabine and cisplatin (GCD) chemotherapy is emerging as a promising regimen, although more evidence is needed for its effectiveness. Methods: This retrospective single-center study involved 44 patients receiving GCD treatment between January 2023 and March 2024 with a median follow-up of 10 months. Outcomes focused on overall survival (OS), progression-free survival (PFS), response rates, and adverse events (AEs). Results: The overall response rate (ORR) was 23%, and the disease control rate (DCR) was 82%. The overall median OS and PFS were 15.3 and 8.0 months, respectively, with patients receiving primary chemotherapy experiencing longer survival compared to a control group. Patients who did not undergo bile duct drainage had statistically different better OS and PFS. Grade 3 or higher AEs occurred in 54.5% of patients, with neutropenia and biliary infections being common. Conclusions: GCD chemotherapy shows potential as an effective treatment for BTCs. The favorable treatment outcome was the response rate, particularly in primary therapy or those cases with no metastasis. Bile duct management is crucial for improving patient outcomes. GCD chemotherapy has a high response rate, PFS, and OS compared to other forms of chemotherapy.

Malignant hilar obstruction usually presents in advanced-stage disease with a poor prognosis. Effective biliary drainage is essential for the beginning of palliative chemotherapy. There is a debate on the amount of liver parenchyma that should be drained to achieve clinical success. This study aimed to correlate the volume of liver drained with clinical success rate.

The authors conducted a retrospective study including patients with malignant hilar biliary obstruction who underwent retrograde endoscopic cholangiography for biliary drainage from January 2014 to December 2018. The main outcome was a correlation of clinical success rate with hepatic volume drained. Secondary outcomes were correlation of clinical success rate with the quantity of liver sectors drained and unilateral versus bilateral drainage.

82 patients met inclusion criteria (58.5 % female), with a mean age of 60±13 years. The main cause of hilar obstruction was cholangiocarcinoma (32.9 %) followed by lymph node metastasis (23.2 %). Technical success was achieved in 75 patients (91.5 %), and clinical success in 45 patients (60 %). The authors found a significant correlation between clinical success rate when at least 50 % of viable parenchyma was drained (p = 0.016; OR = 4.15, 95 % CI 1.4-12.5). Considering liver sectors, higher clinical success rates were found when at least 2 sectors were drained (p < 0.001; OR = 8.50, 95 % CI 2.7-26.7). The correlation between unilateral versus bilateral drainage and clinical success was not statistically significant.

Drainage of at least 50 % of volume hepatic parenchyma was associated with better outcomes as well as drainage of at least 2 hepatic sectors, regardless of if unilateral or bilateral.

Endoscopic trisectoral metal stent (MS) placement for malignant hilar biliary obstruction (MHBO) poses technical challenges, although it may prolong survival and stent patency. Combined stent-by-stent and stent-in-stent (SBSIS) methods can reduce technical difficulty. This study aimed to examine the use of the SBSIS in patients with Bismuth type III or IV MHBO.

This prospective pilot study enrolled 30 eligible patients between January 2020 and October 2022. The study outcomes included technical and clinical success, recurrent biliary obstruction (RBO), and adverse events (AE) besides RBO associated with SBSIS for MHBO.

The technical success rate was 93.3% (28/30 patients). Clinical success was achieved in all patients with technical success. The early and late AEs rates were 6.7% (2/30) and 7.1% (2/28), respectively. The incidence of RBO was 35.7% (10/28). RBO was treated with an endoscopic transpapillary approach in eight patients and an endoscopic ultrasound-guided transmural approach in two patients. The median time to RBO was 162 days, and the median overall survival was 148 days.

This first prospective study investigating the SBSIS method demonstrated good technical feasibility with a low AE rate. Therefore, it can be considered a better option when contemplating trisectoral MS placement for high-grade MHBO.

Malignant hilar biliary obstruction (MHBO) can cause obstructive jaundice and/or cholangitis necessitating appropriate biliary drainage. Endoscopic biliary stenting is the first-choice treatment, especially in unresectable cases, owing to its minimally invasive nature and utility. However, the hilar region is complex because of the branching and curving of bile ducts, making strictures in this area more complicated. Therefore, MHBO stenting is challenging, and treatment strategies have yet to be established. Furthermore, recent advances in antitumor therapies have altered the background surrounding the development of stenting strategies. Therefore, it is necessary to understand and grasp the current evidence well and to accumulate additional evidence reflecting the current situation. This study reviews the current status, issues, and prospects of endoscopic stenting for MHBO, especially in unresectable cases.

Background and study aims Endoscopic ultrasound-guided hepaticogastrostomy with bridging between the left and right bile ducts is an alternative to endoscopic transpapillary drainage for malignant hilar biliary obstruction. We aimed to analyze the long-term stent patency of endoscopic ultrasound-guided hepaticogastrostomy with bridging. Patients and methods Patients who underwent endoscopic ultrasound-guided hepaticogastrostomy with bridging between April 2018 and July 2023 were retrospectively analyzed. We retrospectively compared the stent patency of these patients with that of the individuals who underwent endoscopic transpapillary drainage-multi-stenting using unmatched (entire) and propensity score-matched cohorts. Results Endoscopic ultrasound-guided hepaticogastrostomy with bridging had a technical success rate of 90% (18/20). Adverse events were minimal. The number of clinical success cases was 17 and 82 for endoscopic ultrasound-guided hepaticogastrostomy with bridging using metallic stent and endoscopic transpapillary drainage-multi-stenting, respectively. The recurrent biliary obstruction rate was 17.6% and 58.5% for endoscopic ultrasound-guided hepaticogastrostomy with bridging and endoscopic transpapillary drainage-multi-stenting, respectively; the median time to recurrent biliary obstruction (days) was significantly longer for endoscopic ultrasound-guided hepaticogastrostomy with bridging in the entire (not reached vs. 104, P =0.03) and propensity score-matched (183 vs. 79, P =0.05) cohorts. The non-recurrent biliary obstruction rate for endoscopic ultrasound-guided hepaticogastrostomy with bridging was 91.6% at 3 and 6 months and 57% at 12 months. Multivariate analyses revealed that endoscopic ultrasound-guided hepaticogastrostomy with bridging contributed to a lower recurrent biliary obstruction incidence (hazard ratio, 0.31, P =0.05) without significant difference. Conclusions Stent patency was significantly better for endoscopic ultrasound-guided hepaticogastrostomy with bridging. However, future prospective studies are needed.

Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021.

Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop.

In November 2021, the finalized draft was presented for public scrutiny during a formal hearing.

The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

This document is a summary of the French intergroup guidelines of the management of biliary tract cancers (BTC) (intrahepatic, perihilar and distal cholangiocarcinomas, and gallbladder carcinomas) published in September 2023, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org).

This collaborative work was conducted under the auspices of French medical and surgical societies involved in the management of BTC. Recommendations were graded in three categories (A, B and C) according to the level of scientific evidence until August 2023.

BTC diagnosis and staging is mainly based on enhanced computed tomography, magnetic resonance imaging and (endoscopic) ultrasound-guided biopsy. Treatment strategy depends on BTC subtype and disease stage. Surgery followed by adjuvant capecitabine is recommended for localised disease. No neoadjuvant treatment is validated to date. Cisplatin-gemcitabine chemotherapy combined to the anti-PD-L1 inhibitor durvalumab is the first-line standard of care for advanced disease. Early systematic tumour molecular profiling is recommended to screen for actionable alterations (IDH1 mutations, FGFR2 rearrangements, HER2 amplification, BRAFV600E mutation, MSI/dMMR status, etc.) and guide subsequent lines of treatment. In the absence of actionable alterations, FOLFOX chemotherapy is the only second-line standard-of-care. No third-line chemotherapy standard is validated to date.

These guidelines are intended to provide a personalised therapeutic strategy for daily clinical practice. Each individual BTC case should be discussed by a multidisciplinary team.

Although intraductal plastic stent (IS) placement is an effective treatment for unresectable malignant hilar biliary obstruction (UMHBO), the effectiveness of unilateral and bilateral IS drainage remains controversial. This retrospective study investigated the effectiveness of bilateral IS placement for UMHBO using the propensity score matching method.

Patients who underwent transpapillary endoscopic stenting for UMHBO were analyzed for technical and clinical success, adverse events, and time to recurrent biliary obstruction (TRBO).

A total of 321 patients were enrolled in the study with 27 patients in each unilateral and bilateral IS group in the propensity score-based cohort. Technical success was 100%, while clinical success was 93% and 96% in the unilateral and bilateral IS groups, respectively (p = 1.0). Cholecystitis occurred in 4% and 7%, respectively (p = 1.0). The median TRBO was shorter in the unilateral group (129 [5-383] days) than that in the bilateral group (226 [16-563] days) (p = .0281). Bilateral IS placement was an independent long TRBO factor (hazard ratio [HR] 0.46; 95% confidence interval [CI]: 0.21-0.97; p = .041).

Unilateral and bilateral IS placement had high technical and clinical success rates in primary stent placement. However, bilateral IS placement showed a longer TRBO. Bilateral IS placement may be a good option for initial UMHBO drainage.

We aimed to evaluate the efficacy and safety of metal stents compared with plastic stents when bilateral side-by-side stents were deployed for malignant hilar biliary obstruction (MHBO).

Fifty patients with unresectable advanced MHBO were randomly assigned to the metal stent (MS, n = 25) or plastic stent group (PS, n = 25). Fully covered self-expandable metal stents with 6 mm diameter and plastic stents with either 7F straight or double pigtail were used for MS and PS groups, respectively. Time to recurrent biliary obstruction (TRBO) was evaluated as the primary outcome.

Both groups had 100% technical success rates; 88% and 76% of clinical success rates were obtained in MS and PS, respectively. Although stent migrations were more frequent in MS than PS (48% vs. 16%, P = 0.02), the mean TRBO was significantly longer in MS (190 days; 95% confidence interval [CI] 121-260 days vs. 96 days; 95% CI 50-141 days, P = 0.02). The placement of plastic stents (hazard ratio 2.42; 95% CI 1.24-4.73; P = 0.01) was the only significant risk factor associated with TRBO in multivariable analysis. The rates of adverse events were similar between the two groups (difference 0%; 95% CI -25% to 25%; P > 0.99).

During bilateral side-by-side deployment in MHBO, the use of metal stents appears to be preferable to plastic stents in terms of TRBO, despite a higher frequency of stent migration.

Primary biliary tract tumors are malignancies that originate in the liver, bile ducts, or gallbladder. These tumors often present with jaundice of unknown etiology, leading to delayed diagnosis and advanced disease. Currently, several palliative treatment options are available for primary biliary tract tumors. They include percutaneous transhepatic biliary drainage (PTBD), biliary stenting, and surgical interventions such as biliary diversion. Systemic therapy is also commonly used for the palliative treatment of primary biliary tract tumors. It involves the administration of chemotherapy drugs, such as gemcitabine and cisplatin, which have shown promising results in improving overall survival in patients with advanced biliary tract tumors. PTBD is another palliative treatment option for patients with unresectable or inoperable malignant biliary obstruction. Biliary stenting can also be used as a palliative treatment option to alleviate symptoms in patients with unresectable or inoperable malignant biliary obstruction. Surgical interventions, such as biliary diversion, have traditionally been used as palliative options for primary biliary tract tumors. However, biliary diversion only provides temporary relief and does not remove the tumor. Primary biliary tract tumors often present in advanced stages, making palliative treatment the primary option for improving the quality of life of patients.

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Endoscopic management of unresectable hilar malignant biliary obstruction (HMBO) is technically challenging, and effectiveness of stent-in-stent using large-cell, metal stents was reported. A new, large-cell stent with a 6F tapered delivery system was recently developed. The aim of this study was to compare clinical outcomes of slim-delivery and conventional large-cell stents.

This was a multicenter retrospective comparative study of stent-in-stent methods using slim-delivery stents (Niti-S Large Cell SR Slim Delivery [LC slim-delivery]) and conventional stents (Niti-S large-cell D-type; LCD) for unresectable HMBO.

Eighty-three patients with HMBO were included; 31 LC slim-delivery and 52 LCD. Overall technical and clinical success rates were 100% and 90% in LC slim-delivery group and 98% and 88% in LCD group. Use of the LC slim-delivery was associated with shorter stent placement time in the multiple regression analysis, with a stent placement time of 18 and 23 min in LC slim-delivery and LCD groups, respectively. The early adverse event (AE) rate of LC slim-delivery was 10%, with no cholangitis or cholecystitis as compared to 23% in the LCD group. Recurrent biliary obstruction (RBO) rates and time to RBO were comparable between the two groups: 35% and 44%, and 8.5 and 8.0 months in LC slim-delivery and LCD groups, respectively. The major cause of RBO was tumor ingrowth (82%) in the LC slim-delivery group and sludge (43%) and ingrowth (48%) in LCD group.

Stent-in-stent methods using LC slim-delivery shortened stent placement time with low early AE rates and comparable time to RBO in patients with HMBO.

Endoscopic ultrasound (EUS)-guided biliary drainage is being increasingly performed as an alternative to percutaneous transhepatic biliary drainage (PTBD) to treat malignant hilar obstruction (MHO) after failed endoscopic retrograde cholangiopancreatography (ERCP). However, no study has compared EUS-guided hepaticoduodenostomy (EUS-HDS) with PTBD for right intrahepatic duct (IHD) obstruction after failed ERCP in patients with unresectable MHO.

We retrospectively reviewed the data of consecutive patients with right IHD obstruction developed by unresectable MHO who underwent EUS-HDS or PTBD after a previous placement of a stent in the left and/or right IHD between March 2018 and October 2021. Technical success, clinical success, stent or tube-related adverse events, frequency of reintervention, and stent patency were evaluated.

A total of 42 patients (18 EUS-HDS, 24 PTBD) were analyzed. Both groups did not show significant differences in technical success (EUS-HDS, 94% vs PTBD, 100%; P = 0.429), clinical success (83% vs 83%; P = 0.999), early adverse events (24% vs 46%; P = 0.144), and stent or tube-related late adverse events (29% vs 54%; P = 0.116). During follow-up, the EUS-HDS group had a longer median duration of patency (131 days vs 58.5 days; P = 0.041), and lower mean frequency of reinterventions per patient (0.35 vs 1.92; P = 0.030) than the PTBD group.

EUS-HDS showed comparable efficacy and safety to PTBD for drainage of the right biliary system and produced longer duration of patency and lower frequency of reinterventions in patients with unresectable MHO.

The appropriate duration of antimicrobial therapy for acute cholangitis (AC) arising from multiple hilar biliary obstructions as opposed to simple obstruction in the extrahepatic bile duct has not been established. This study assessed the efficacy of the duration of antimicrobial treatments in the Tokyo Guidelines 2018 for AC based on the cause and site of obstruction.

This single-center retrospective study involved patients with AC who underwent successful biliary drainage and completed a 7-day or shorter antimicrobial treatment. Patients were categorized into three groups: Group 1, bile duct stone or benign obstruction; Group 2, simple biliary obstruction due to malignancy; and Group 3, multiple hilar biliary obstruction due to malignancy. The primary outcome was clinical cure rate, and the secondary outcomes were 3-month recurrence rate and length of hospital stay.

A total of 373 patients were selected. Patients in Group 3 were younger or had Charlson Comorbidity Index ≥4, and had fewer positive blood cultures. In Group 3, the clinical cure rate (87.1%) and 3-month recurrence rate (32.3%) were less favorable than those in the other groups. In Group 1, the clinical cure rate was significantly higher (98.1%, P = 0.02) with a much lower 3-month recurrence rate of only 3.4% (P < 0.001) than that in the other groups. The median hospital stay for all groups was 7 days.

This study suggests that the outcomes in Group 3 may be worse than those in Groups 1 or 2, regardless of the duration of the antibiotic treatment.

In patients with unresectable malignant hilar biliary obstruction (UMHBO), drainage of ≥ 50% liver volume correlates with better clinical outcomes. Accurately measuring the liver volume to be drained by biliary stents is required. We aimed to develop a novel method for calculating the drained liver volume (DLV) using a 3D volume analyzer (3D volumetry), and assess the usefulness for drainage in patients with UMHBO.

Three-dimensional volumetry comprises the following steps: (1) manual tracing of bile duct using 3D imaging system; (2) 3D reconstruction of bile duct and liver parenchyma; and (3) calculating DLV according to the 3D distribution of bile ducts. Using 3D volumetry, we reviewed data of patients who underwent biliary drainage for UMHBO, calculated the DLV, and determined the association between DLV and biliary drainage outcome.

There were 104 eligible cases. The mean DLV was 708 ± 393 ml (53% ± 21%). and 65 patients (63%) underwent drainage of   ≥50% liver volume. The clinical success rate was significantly higher in patients with DLV ≥ 50% than in patients with DLV < 50% (89% vs. 28%, P < 0.001). The median time to recurrence of biliary obstruction (TRBO) and survival time were significantly longer in patients with DLV ≥ 50% than in patients with DLV < 50% (TRBO, 292 vs. 119 days, P = 0.03; survival, 285 vs. 65days, P = 0.004, log-rank test, respectively).

Three-dimensional volumetry, a novel method to calculate DLV accurately according to bile duct distribution was useful for drainage in UMHBO patients.