In patients with perihilar cholangiocarcinoma (pCCA) who are considered for surgical resection, biliary drainage of the future liver remnant (FLR) is essential. The conventional approach is placement of a transpapillary plastic stent during endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP is associated with considerable risks, including cholangitis (37%), stent dysfunction (19%) and post-ERCP pancreatitis (19%) within 90 days (1). Some of these complications may result from bridging the papilla, which leads to duodenobiliary reflux and colonization of the biliary tract with upper gastrointestinal flora, increasing the risk of cholangitis. To mitigate these risks while preserving ease of removal, a suprapapillary stent equipped with a retrieval string could offer a viable alternative. The primary aim was to evaluate the safety and feasibility of preoperative endobiliary drainage using a suprapapillary plastic stent with a retrieval string. 

This prospective single-center pilot study included patients with pCCA eligible for hemihepatectomy. Patients were excluded when the stricture was located ≤2 cm from the papilla. Procedures were performed using a modified plastic biliary stent (7, 8.5 or 10 Fr) with a retrieval string attached distally. The primary outcome was safety, defined as the number of severe drainage related complications until exploratory laparotomy. Severe complications are defined as any complication leading to additional invasive interventions, admission to hospital, or death. Secondary endpoints included technical and clinical success rates, defined as successful placement of the stent and a ≥20% reduction in bilirubin levels at day 7, respectively. Patients underwent a scheduled stent exchange if surgery had not taken place after 6-12 weeks, depending on the diameter of the stent.

Between March 2023 and August 2025, 40 patients with presumed resectable pCCA were enrolled (14 female [35%], median age 72 years [IQR 65-76]. Bismuth classification was distributed as follows: type I (1, 3%), type II (4, 10%), type IIIa (19, 48%), type IIIb (3, 8%), and type IV (13, 33%). Suprapapillary stent placement was technically successful in the first procedure in all cases (40/40, 100%), in 35 patients one stent was placed (35/40, 88%) and in five patients two stents (5/40, 13%) were placed. A precut sphincterotomy was performed during the procedure in four patients (4/40, 10%), and five patients (5/40, 13%) had undergone a sphincterotomy prior to referral. Eleven patients (11/40, 28%) had one or more severe drainage related adverse event following the index procedure within 90 days. Cholangitis occurred in four of these patients (4/40, 10%), of which one case was associated with stent dysfunction (1/40, 3%); in the remaining three cases (3/40, 8%) there were no signs of stent dysfunction. Stent dysfunction without cholangitis occurred in five patients (5/40, 13%), caused by partial migration (n=3; one inward, two outward) or occlusion with debris (n=2). Four patients (4/40, 10%) developed post-ERCP pancreatitis. Clinical success was achieved after the initial procedure in 34/39 (87%) patients, with a minimum follow-up of two weeks. In one patient, clinical success could not be evaluated due to death within two weeks, resulting from rapid clinical deterioration. Overall, 29 patients underwent surgical exploration or scheduled stent exchange without the need for an unplanned re-intervention (29/40, 72%). Nineteen patients (19/40, 48%) ultimately underwent surgical resection. One patient remains under evaluation for liver transplantation. Surgery was not performed in 20/40 (50%) included patients. In 14 patients this was due to locally advanced or metastatic disease, in two patients due to inadequate FLR volume, in one due to patient withdrawal, and three patients died prior to surgery.  

This prospective pilot study demonstrates that endoscopic biliary drainage using a suprapapillary plastic stent with a retrieval string is both technically feasible and appears safe in patients with potentially resectable pCCA. Most patients did not require any unplanned re-intervention, and the incidence of cholangitis was substantially lower compared with previous studies (1). Larger comparative trials are warranted to further evaluate its efficacy, and define its role within the preoperative management strategy for pCCA.