Endoscopic biliary drainage techniques for bilirubin normalization in distal malignant biliary obstruction: A comprehensive review

doi:10.4253/wjge.v18.i6.121737

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World Journal of Gastrointestinal Endoscopy

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1948-5190

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastrointest Endosc. Jun 16, 2026; 18(6): 121737
Published online Jun 16, 2026. doi: 10.4253/wjge.v18.i6.121737

Endoscopic biliary drainage techniques for bilirubin normalization in distal malignant biliary obstruction: A comprehensive review

Alberto Martino, Antonino Granata, Francesco Paolo Zito, Massimiliano Lombardi, Roberto Fiorentino, Claudio Carrubba, Luigi Orsini, Raffaella Niola, Ferdinando Riccardi, Giuseppe Galloro, Carlo Molino, Giovanni Lombardi

Alberto Martino, Francesco Paolo Zito, Luigi Orsini, Giovanni Lombardi, Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy

Antonino Granata, Interventional Endoscopic Unit, Buccheri La Ferla Hospital, Palermo 90123, Italy

Massimiliano Lombardi, Giuseppe Galloro, Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, University “Federico II” of Naples, Napoli 80131, Italy

Roberto Fiorentino, Ferdinando Riccardi, Department of Oncology, AORN “Antonio Cardarelli”, Napoli 80131, Italy

Claudio Carrubba, Raffaella Niola, Department of Interventional Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy

Carlo Molino, Department of Oncological Surgery, AORN “Antonio Cardarelli”, Napoli 80131, Italy

Author contributions: Martino A, Granata A, and Zito FP designed the research, wrote and edited the manuscript, and finalized the text; Martino A, Granata A, Zito FP, Lombardi M, Fiorentino R, Carrubba C, and Orsini L performed the literature search and analyzed the data; Niola R, Riccardi F, Galloro G, Molino C, and Lombardi G reviewed the paper for important intellectual content; and all authors have read and approved the final manuscript.

AI contribution statement: The authors take full responsibility for the accuracy, integrity, and originality of the manuscript. AI tools were not used to generate data, perform analyses, or draw scientific conclusions.

Conflict-of-interest statement: The authors have no conflicts of interest to declare.

Corresponding author: Alberto Martino, MD, Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Via Antonio Cardarelli 9, Napoli 80131, Italy. alberto.martino@aocardarelli.it

Received: March 31, 2026
Revised: April 30, 2026
Accepted: May 15, 2026
Published online: June 16, 2026
Processing time: 71 Days and 8.5 Hours

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is currently recommended as the gold standard treatment modality for distal malignant biliary obstruction (DMBO), with percutaneous transhepatic biliary drainage being historically regarded as the second-line strategy in case of ERCP failure. Following the recent advent of therapeutic endoscopic ultrasound, various endoscopic ultrasound-guided biliary drainage techniques have been advocated as the preferred second-line options, as they are associated with fewer adverse events and morbidity compared to percutaneous transhepatic biliary drainage. Moreover, they have also been proposed as promising first-line alternatives to ERCP. However, the capability of both the historical and emerging biliary drainage modalities to normalize total bilirubin in patients with DMBO is underreported and evidence is still lacking, especially regarding the emerging ones. Notably, bilirubin normalization is regarded as mandatory before starting chemotherapy, thus representing a crucial outcome of any biliary drainage method for DMBO. Our study summarizes and discusses the current evidence regarding the effectiveness of currently available endoscopic biliary drainage techniques for bilirubin normalization in DMBO.

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

Core Tip: Endoscopic retrograde cholangiopancreatography remains the gold standard for distal malignant biliary obstruction (DMBO), with endoscopic ultrasound-guided biliary drainage emerging as a promising alternative. However, evidence regarding bilirubin normalization rates across these modalities is lacking. Our study reviews the available evidence to evaluate the efficacy of endoscopic biliary drainage techniques in normalizing bilirubin levels in patients with DMBO.