Stent selection in elderly biliary drainage: A pragmatic guide from benign to malignant

The aging global population presents a growing challenge in interventional endoscopy, making the study by Sugimoto <i>et al</i> both timely and relevant. Their retrospective analysis provides crucial data to resolve a common clinical dilemma: Plastic stent (PS) or metal stent (MS) for endoscopic ultrasound-guided biliary drainage in patients aged 70 and older? This editorial contextualizes their key finding, that PS and MS offer comparable patency in mixed cohorts, but MS significantly prolongs time to recurrent biliary obstruction in malignant cases without antegrade stenting, into a practical decision-making framework. We argue that for benign disease, the ease of PS reintervention is paramount in a frail population. Conversely, for malignancy, the goal shifts to maximizing stent patency to minimize the physical and psychological burden of repeated procedures, firmly favoring the use of MS. This work is a significant step toward personalized, age-specific biliary drainage strategies, and we discuss the imperative for future prospective trials to solidify these recommendations.