Should We Be Aiming For A “Stent-first Strategy” in the Management of Malignant Biliary Obstruction? A Retrospective Single-Center Analysis

Background Percutaneous transhepatic cholangiography (PTC) is essential when endoscopic retrograde cholangiopancreatography (ERCP) fails or is contraindicated. Despite emerging evidence favoring primary stenting, data directly comparing it with the traditional two-staged drainage approach remain scarce. Purpose To evaluate the efficacy, complication rates, and reintervention burden of initial stent placement versus drainage. Material and Methods A retrospective single-center analysis of 96 patients undergoing PTC (2021–2024) was conducted; 95 received intervention (primary stent n = 30, drain n = 65). Outcomes (bilirubin kinetics, clinical success, complications, reinterventions) were compared using Welch's t -test, chi-square test, or Fisher's exact test, with multivariable adjustment for baseline differences. Results Malignant obstruction accounted for 96.8% of cases; technical success was 97.9% (CIRSE standards). Bilirubin reduction was greater with stents (45.7% vs. 35.5%; mean difference 10.2 percentage points, 95% confidence interval = 0.3–20.0; P = 0.043), attenuated after adjustment ( β = 9.8 pp; P = 0.093). Complications, all reinterventions, and combined adverse events were lower with stents (23.3% vs. 55.4%, 16.7% vs. 73.8%, and 30.0% vs. 86.2%; all P ≤0.004); adjusted analyses confirmed independently reduced odds (adjusted odds ratio = 0.26, 0.08, and 0.07, respectively). Clinical success trended higher with stents (46.7% vs. 38.5%) but was not statistically significant. Overall, 30-day mortality was 17.7% with 2% procedure-related. Median post-intervention survival was 101 days. Conclusion In this retrospective single-center cohort, a stent-first approach was associated with greater bilirubin reduction and fewer complications and reinterventions than drainage-first, without compromising technical success or survival. Findings are hypothesis-generating and require prospective multicenter validation.