Management of malignant distal biliary obstruction

The most common cause of malignant distal biliary obstruction is pancreatic cancer, as 70–90% of patients will develop jaundice during the course of their disease. Pancreatic cancer is usually advanced at presentation, and curative resection is possible in < 15% of patients. If a patient is to undergo early surgical resection, biliary drainage is not prerequisite. Early surgery without preoperative biliary drainage does not increase the risk of complications, as compared with preoperative biliary drainage, followed by surgery. Postoperative complications do not differ significantly between the two approaches. In light of no significant improvements in patient survival in large trials of a surgery-first followed by adjuvant therapy over the past 2 decades, there has been a shift towards preoperative neoadjuvant chemotherapy in the setting of borderline resectable disease. Consequently, effective preoperative biliary drainage has become a paramount concern in this setting. Multiple retrospective and prospective studies have compared the outcomes between covered metal stents and uncovered metal stents in malignant biliary obstruction. In patients undergoing neoadjuvant chemoradiation or surgical resection, no significant self-expanding metal stent-related complications or adverse events were seen. Additionally, no significant difference in overall survival was seen between the two groups. Within the palliative realm, self-expanding metal stents have also become the stent of choice with greater duration of patency. In an effort to deliver a survival benefit, there are many ongoing trials and developments in the realm of the therapeutic endoscopy. In this review, we will examine what we have accomplished and further explore the potential benefits of endoscopic interventions on the horizon.