INTRODUCTION
The demographic shift toward population aging is redefining therapeutic priorities in gastroenterology[1]. Endoscopic interventions must now be tailored not only to disease etiology but also to the physiological vulnerabilities of older patients, who often present with frailty, multimorbidity, and polypharmacy, factors that directly influence procedural risk tolerance and goals of care. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an invaluable alternative to endoscopic retrograde cholangiopancreatography (ERCP) when traditional access fails because of altered anatomy, malignant duodenal obstruction, or surgically reconstructed biliary pathways[2,3]. Over the past decade, advances in device design and operator experience have allowed EUS-BD to transition from a salvage technique to a mainstream drainage strategy, with clinical success and adverse event profiles comparable to ERCP in expert centers[4,5].
However, stent selection remains a central uncertainty, particularly in elderly cohorts often excluded from randomized controlled trials. Plastic stents (PS) are inexpensive, easy to insert, and readily replaced, making them appealing for patients requiring multiple interventions. In contrast, self-expandable metal stents (MS) offer superior patency, reducing recurrent biliary obstruction and hospitalization, but they are costlier and more technically demanding[6,7]. In geriatric practice, this choice is more than procedural; it embodies a balance between durability and tolerance. Sugimoto et al[8] addressed this critical question in a multicenter retrospective study analyzing outcomes of EUS-BD among patients aged ≥ 70 years. They demonstrated that while PS and MS achieved comparable patency in the general elderly cohort, MS significantly prolonged time to recurrent biliary obstruction (TRBO) in malignant cases without antegrade stenting (AGS). This editorial situates their work within the evolving evidence base, explores its clinical implications, and proposes a rational, patient-oriented approach to stent selection in elderly biliary drainage.
BODY
The study by Sugimoto et al[8] addresses this clinical crossroad directly. In their retrospective analysis of 64 patients aged 70 years or older undergoing successful EUS-BD, the authors compared the TRBO between PS and MS. While no significant difference was found across the entire cohort, a striking pattern emerged when the analysis was limited to malignant obstruction without AGS: MS achieved a significantly longer TRBO (6-month RBO rate 20.7% vs 63.3%, P = 0.036). This specific benefit in the malignancy-without-AGS subgroup may be because AGS itself improves drainage efficacy, thereby diminishing the relative advantage of the MS, or because this subgroup represents a more homogeneous population where the stent's intrinsic properties become the dominant variable. This finding represents a pivotal signal, one that moves the discussion from anecdote to data-driven guidance.
The evolving evidence landscape
Endoscopic ultrasound-guided drainage has matured into a safe and effective solution for biliary decompression when ERCP is unfeasible[9,10]. A recent meta-analysis of randomized controlled trials confirmed that EUS-BD and ERCP yield similar rates of technical success, clinical response, and stent patency, while EUS-BD may carry a lower risk of post-procedural pancreatitis[3]. As the aging population expands, the need to define optimal procedural strategies for the elderly becomes pressing. Historically, MS have been favored in malignant biliary obstruction due to their longer patency, whereas PS have been preferred in benign strictures or patients with limited survival[11,12]. Studies have consistently demonstrated that covered MS significantly extends TRBO compared with PS in malignant disease, reducing reintervention frequency and hospitalizations[13,14]. The work of Sugimoto et al[8] adds an essential layer to this narrative by focusing specifically on older patients, a demographic characterized by frailty, comorbidity, and heterogeneous prognosis. Their finding of equivalent patency overall but clear superiority of MS in malignant cases without AGS suggests that age should not, by itself, deter the use of MS in appropriately selected elderly individuals.
Stent choice in benign disease: Prioritizing reintervention ease
In benign biliary disease, endoscopic management often requires multiple sessions for stent exchange and tract maintenance. For elderly patients, procedural tolerance, sedation risk, and overall resilience are paramount considerations. PS offers several advantages in this context. They are easier to deploy through narrow tracts, rarely migrate, and can be exchanged without complex maneuvers[15,16]. Moreover, PS facilitates repeat interventions through stable, mature fistulous tracts, whereas MS may provoke tissue hyperplasia that complicates reaccess[17]. From a physiologic standpoint, minimizing procedural duration and electrocautery use reduces cardiopulmonary stress, a benefit particularly relevant in geriatric patients with limited physiological reserve[18]. For benign biliary strictures, the expected need for periodic exchange fits within the framework of chronic disease management, allowing scheduled, low-risk procedures under optimized sedation. Accordingly, PS remains the first-line option in benign disease when endoscopic access is straightforward, and reintervention feasibility is essential.
Stent choice in malignant disease: Prioritizing patency and patient comfort
In malignancy, the therapeutic objective shifts toward palliation, with emphasis on quality of life, avoidance of recurrent cholangitis, and minimization of procedure-related distress. In such cases, the superior patency of MS, routinely extending beyond six months, is clinically decisive[8,13,19]. Covered MS prevents tumor ingrowth and reduces the need for repeat interventions, making them particularly valuable in elderly patients with limited survival expectancy or those receiving palliative chemotherapy[19]. The burden of recurrent jaundice or frequent hospital readmissions can be devastating for older individuals, contributing to physical decline and psychological distress. Each reintervention carries incremental anesthetic and infectious risk. Therefore, the “one procedure, long relief” paradigm of MS use aligns with the principles of geriatric palliative endoscopy. Modern fully covered designs have further mitigated complications such as bile leakage and stent migration, enhancing the safety of EUS-BD in this population[20].
Integrating evidence into clinical decision-making
The decision between PS and MS should integrate patient comorbidity, disease etiology, anatomical considerations, and life expectancy. For benign obstruction, PS remains advantageous due to its simplicity and flexibility. For malignant obstruction, particularly in the absence of AGS, MS provides superior outcomes by prolonging stent patency and minimizing repeated interventions[8,14,19]. In cases with complex anatomy or ascites, MS also reduces leakage risk and ensures secure placement[15]. Although MSs entail a higher initial cost, this expense may be offset by the reduced need for reinterventions and hospital readmissions associated with their longer patency in malignant obstruction, making them a potentially cost-effective option, particularly in palliative settings[14]. Operator experience remains a key determinant of success. The learning curve for EUS-BD is steep, and adverse events decrease significantly with increasing procedural volume[9]. Establishing institutional protocols to standardize stent selection criteria, integrating age, frailty indices, and anatomical feasibility, will further optimize safety and outcomes.
These results allow clinicians to move beyond a one-size-fits-all mentality and toward an etiology-driven algorithm. For benign biliary disease, such as stones or anastomotic strictures, the practical advantages of PS, including ease of removal and exchange, outweigh theoretical patency differences. Conversely, for malignant obstruction, especially when palliation is the goal, the extended patency of MS translates into fewer hospitalizations, less sedation exposure, and enhanced patient comfort. In essence, PS are for the patient we will see again; MS are for the patient we hope not to need to see again.
Acknowledging limitations and the path forward
As with any retrospective study, caution is warranted. The sample size for MS in the Sugimoto et al[8] cohort was modest (n = 13), and stent choice was not randomized, leaving room for selection bias. It is conceivable that patients selected for MS had more favorable anatomy or disease features. Nonetheless, these data provide the ethical and methodological justification for a prospective randomized trial, “PS vs MS for EUS-BD in patients ≥ 70 with malignant distal obstruction”. Such a study could definitively establish practice standards while incorporating frailty metrics, cost analyses, and patient-reported outcomes to ensure that efficacy is aligned with lived experience.
Research gaps and future directions
Although the study by Sugimoto et al[8] provides a meaningful contribution, several gaps remain. Prospective multicenter trials with standardized definitions, such as the TOKYO criteria for recurrent biliary obstruction[17], are required to confirm these findings. Future research should stratify patients by frailty rather than chronological age, incorporate patient-reported outcome measures, and evaluate cost-effectiveness in health-economic models. An ideal future trial would therefore be a multicenter, randomized controlled trial that not only compares PS and MS but also stratifies enrollment by a validated frailty index and incorporates quality-of-life metrics as a primary endpoint. Emerging technologies may soon alter the landscape of biliary drainage. Biodegradable stents and drug-eluting designs are under development, aiming to combine the removability of PS with the longevity of MS[20]. Artificial-intelligence-based predictive models may also help identify which patients are most likely to benefit from each stent type, ushering in a precision-endoscopy era for biliary drainage in the elderly.
CONCLUSION
The challenge of stent selection in elderly biliary drainage exemplifies the intersection of technical precision and humane medicine. For benign disease, PS offers a pragmatic solution that balances efficacy with procedural safety and ease of reintervention. For malignant obstruction, MS delivers the durability required to preserve comfort and dignity by minimizing repeat procedures. The study by Sugimoto et al[8] has moved the field closer to an evidence-based, patient-centered approach that acknowledges both anatomical and human complexity. Future prospective trials integrating geriatric assessment and patient preference will be crucial to refining these recommendations. In the evolving landscape of interventional endoscopy, the optimal stent is not only the one that functions best, but the one that best serves the patient’s life. The choice between PS and MS in the elderly is more than a procedural preference; it is a reflection of how we value comfort, dignity, and individualized care in the final chapters of life. Sugimoto et al[8] have provided the data; it is now upon the endoscopic community to translate evidence into wisdom.
