Biliary drainage routes: ERCP stent, percutaneous (PTC) and EUS-guided

Gallbladder cancer causes jaundice by invading the hepatic hilum or the common bile duct, which is a sign of advanced disease. Drainage is needed before chemotherapy (bilirubin must fall) and for symptom relief. ERCP with a self-expanding metal stent is first line for distal obstruction. Percutaneous transhepatic drainage is used for hilar obstruction, after failed ERCP, or when the duodenum is inaccessible; a randomised comparison of percutaneous versus endoscopic drainage for malignant hilar obstruction (INTERCPT) was stopped for slow accrual, and an earlier trial in resectable perihilar cancer stopped for higher mortality with the percutaneous arm, so the choice remains centre-dependent. The Dutch TESLA trial is randomising primary percutaneous stenting above the ampulla against endoscopic drainage for unresectable hilar obstruction, gallbladder cancer included. Endoscopic ultrasound-guided drainage (choledochoduodenostomy or hepaticogastrostomy) matched ERCP for technical success in a 125-patient Korean randomised trial of distal malignant obstruction (93.8 versus 90.2 percent) with fewer adverse events (6.3 versus 19.7 percent), no post-procedure pancreatitis, fewer reinterventions (15.6 versus 42.6 percent) and longer stent patency (85.1 versus 48.9 percent). Cholangitis and stent occlusion are the recurring problems; metal stents stay open longer than plastic ones.