Malignant biliary obstruction often presents with challenges requiring the endoscopist to assess the location of the lesion, the staging of the disease, the eventual resectability and patient preferences in term of biliary decompression. This review will focus on the different modalities available in order to offer the most appropriate palliation, such as conventional endoscopic retrograde cholangiopancreatography, endoscopic ultrasound guided biliary drainage as well as ablative therapies including photodynamic therapy or radiofrequency ablation.

• Biliary obstruction
• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasonography
• Stenting
• Ablation therapy

Percutaneous bilateral biliary stenting is an established method for the management of unresectable malignant hilar biliary obstruction.

To evaluate the efficacy and safety of a novel uncovered biliary stent, specifically designed for hilar reconstruction.

This, single-center, retrospective study included 18 patients (mean age 71 ± 11 years; 61.1% male) undergoing percutaneous transhepatic Moving cell stent (MCS) placement for hilar reconstruction using the stent-in-stent technique for malignant biliary strictures, between November 2020 and July 2021. The Patients were diagnosed with cholangiocarcinoma (12/18; 66.6%), gallbladder cancer (5/18; 27.7%), and colorectal liver metastasis (1/18; 5.5%). Primary endpoints were technical (appropriate stent placement) and clinical (relief from jaundice) success. Secondary endpoints included stent patency, overall survival, complication rates and stent-related complications.

The technical and clinical success rates were 100% (18/18 cases). According to Kaplan-Meier analysis, the estimated overall patient survival was 80.5% and 60.4% at 6 and 12 mo respectively, while stent patency was 90.9% and 68.2% at 6 mo and 12 mo respectively. The mean stent patency was 172.53 ± 56.20 d and median stent patency was 165 d (range 83-315). Laboratory tests for cholestasis significantly improved after procedure: mean total bilirubin decreased from 15.2 ± 6.0 mg/dL to 1.3 ± 0.4 mg/dL (P < 0.001); mean γGT decreased from 1389 ± 832 U/L to 114.6 ± 53.5 U/L (P < 0.001). One periprocedural complication was reported. Stent-related complications were observed in 5 patients (27.7%), including 1 occlusion (5.5%) and 1 stent migration (5.5 %).

Percutaneous hilar bifurcation biliary stenting with the MCS resulted in excellent clinical and technical success rates, with acceptable complication rates. Further studies are needed to confirm these initial positive results.

• Malignant hilar biliary obstructions
• Hilar cholangiocarcinoma
• Self-expandable metallic stent
• Stent-in-stent technique
• Percutaneous approach
• Bilateral Y-stenting

• EUS‐BD
• biliary drainage
• malignant hilar biliary obstruction
• side‐by‐side
• stent‐in‐stent

Cholangiocarcinoma (CCA) is a primary malignancy of the bile ducts with three anatomically and molecularly distinct entities: Intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. As a result of phenotypic and anatomic differences they differ significantly with respect to management. For each type of CCA there have been significant changes in management over the last several years which will be discussed in this review. Although resection remains the standard of care for all types of CCA, liver transplantation has been established as curative treatment for selected patients with pCCA and is being evaluated for iCCA with early success. With respect to systemic therapy capecitabine is now first line adjuvant therapy for all biliary tract malignancies after curative intent resection. Progress in exploiting the pathologic mutations and molecular abnormalities has also yielded regulatory approval of targeted therapy for CCA in patients with acquired alterations in the fibroblast growth factor receptor. There is also increased consensus in managing malignant biliary obstruction associated with CCA where pre-operative biliary stenting is not beneficial while self-expanding metal stents have been shown to be superior to plastic stents in patients who are not surgical candidates.

• Cholangiocarcinoma
• Intrahepatic cholangiocarcinoma
• Perihilar cholangiocarcinoma
• Liver transplantation
• Chemotherapy

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

• benign biliary stricture
• biliary drainage
• guidelines
• malignant biliary strictures
• percutaneous transhepatic biliary drainage

• confocal laser endomicroscopy
• endoscopic retrograde cholangiopancreatography
• endoscopic ultrasound
• malignant hilar strictures
• peroral cholangioscopy
• personalized endoscopy
• plastic biliary stents
• self-expandable metal stents

• Bilateral stenting
• Hilar biliary obstruction
• Jaundice
• Stent patency

Although endoscopic bilateral stent-in-stent placement is challenging, many recent studies have reported promising outcomes regarding technical success and endoscopic re-intervention. This study aimed to evaluate the technical accessibility of stent-in-stent placement using large cell-type stents in patients with inoperable malignant hilar biliary obstruction.

Forty-three patients with inoperable malignant hilar biliary obstruction from four academic centers were prospectively enrolled from March 2013 to June 2015.

Bilateral stent-in-stent placement using two large cell-type stents was successfully performed in 88.4% of the patients (38/43). In four of the five cases with technical failure, the delivery sheath of the second stent became caught in the hook-cross-type vertex of the large cell of the first stent, and subsequent attempts to pass a guidewire and stent assembly through the mesh failed. Functional success was achieved in all cases of technical success. Stent occlusion occurred in 63.2% of the patients (24/38), with a median patient survival of 300 days. The median stent patency was 198 days. The stent patency rate was 82.9%, 63.1%, and 32.1% at 3, 6, and 12 months postoperatively, respectively. Endoscopic re-intervention was performed in 14 patients, whereas 10 underwent percutaneous drainage.

Large cell-type stents for endoscopic bilateral stent-in-stent placement had acceptable functional success and stent patency when technically successful. However, the technical difficulty associated with the entanglement of the second stent delivery sheath in the hook-cross-type vertex of the first stent may preclude large cell-type stents from being considered as a dedicated standard tool for stent-in-stent placement.

• Cholangiopancreatography, endoscopic retrograde
• Cholestasis, intrahepatic
• Klatskin tumor
• Self expandable metallic stents

• malignant hilar biliary obstruction
• placement across the papilla
• recurrent biliary obstruction
• side-by-side placement
• uncovered self-expandable metal stent

• Malignant hilar biliary obstruction
• self-expandable metallic stent
• stent patency
• stent-in-stent

• Adult
• Aged
• Bile Duct Neoplasms/complications
• Bile Duct Neoplasms/surgery
• Carcinoma/complications
• Carcinoma/surgery
• Cholestasis/etiology
• Cholestasis/therapy
• Drainage/methods
• Endoscopy, Digestive System/methods
• Female
• Humans
• Male
• Middle Aged
• Proportional Hazards Models
• Prosthesis Implantation/methods
• Risk Factors
• Self Expandable Metallic Stents
• Stents/adverse effects
• Treatment Outcome

• Bilateral stenting
• Biliary drainage
• Drainage liver volume
• Hilar biliary obstruction
• Unilateral stenting

• Malignant hilar stricture (MHS)
• biliary stent
• palliative treatment

The management of jaundice and cholangitis is important for improving the prognosis and quality of life of patients with unresectable malignant hilar biliary strictures (UMHBS). In addition, effective chemotherapy, such as a combination of gemcitabine and cisplatin, requires the successful control of jaundice and cholangitis. However, endoscopic drainage for UMHBS is technical demanding, and continuing controversies exist in the selection of the most appropriate devices and techniques for stent deployment. Although metallic stents (MS) are superior to the usual plastic stents in terms of patency, an extensive comparison between MS and “inside stents”, which are deployed above the sphincter of Oddi, is necessary. Which techniques are preferred remains as yet unresolved: for instance, whether to use a unilateral or bilateral drainage, or a stent-in-stent or side-by-side method for the deployment of bilateral MS, although a new cell design and thin delivery system for MS allowed us to accomplish successful deployments of bilateral MS. The development of techniques and devices for re-intervention after stent occlusion is also imperative. Further critical investigations of more effective devices and techniques, and increased randomized controlled trials are warranted to resolve these important issues.

• Malignant hilar biliary obstruction
• Biliary drainage
• Metallic stents
• Stent-in-stent
• Side-by-side

• malignant hilar obstruction
• biliary stent
• side-by-side
• stent-in-stent

• Cholestasis/mortality
• Cholestasis/therapy
• Clinical Trials as Topic
• Drainage/methods
• Female
• Humans
• Male
• Publication Bias
• Reproducibility of Results
• Stents
• Treatment Outcome