Letter to the Editor: Bilirubin normalization: A crucial outcome to assess in biliary drainage

Abstract

A recent study by Naidu et al published in the World Journal of Gastrointestinal Endoscopy prospectively evaluated the bilirubin normalization rate and its kinetics following endoscopic retrograde pancreatic cholangiography in both benign and malignant extrahepatic biliary obstructions. This letter highlighted the crucial role of the bilirubin normalization in evaluating the efficacy of any biliary drainage technique, especially in the malignant setting. However, despite its significant impact on clinical and oncological outcomes, the bilirubin normalization rate is often underreported in favor of the clinical success defined by a reduction of total bilirubin of 50%-75% within 2-4 weeks. Nevertheless, this clinical success is not synonymous with bilirubin normalization. The systematic evaluation of this key outcome in a standardized fashion should be strongly encouraged in future trials, especially in those comparing standard-of-care techniques with emerging ones.

Keywords: Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound-guided biliary drainage; Biliary obstruction; Distal biliary obstruction; Distal malignant biliary obstruction; Bilirubin normalization

Core Tip: The bilirubin normalization is a key outcome in biliary drainage, especially in the malignant setting. However, despite its profound effect on clinical and oncological outcomes, the bilirubin normalization rate is generally underreported. Its systematic and standardized assessment should be strongly encouraged in future trials.