Endobiliary radiofrequency ablation for malignant biliary obstruction: clinical benefits, limitations, and future directions

Endobiliary radiofrequency ablation (EB-RFA) is an adjunctive local therapy performed during endoscopic biliary drainage for malignant biliary obstruction. EB-RFA was originally introduced to reduce the intraductal tumor burden and maintain biliary drainage, and has been investigated for its potential survival benefits, especially for patients with extrahepatic cholangiocarcinoma (eCCA). However, the available evidence shows heterogeneity, and recent large trials have reported neutral results. This review summarizes the current evidence regarding the clinical benefits and limitations of EB-RFA, focusing on its effects on survival and stent patency. Existing data suggest that the survival benefit associated with EB-RFA is greater in patients with eCCA without distant metastasis than in those with metastatic disease. Evidence of its efficacy in improving stent patency is inconsistent based on the findings of randomized trials. However, observational studies, particularly those involving uncovered self-expandable metal stents, have reported its benefits. EB-RFA may also be considered for reintervention in cases involving metal stents occluded due to tumor ingrowth; however, clinical success may be suboptimal due to imperfect tissue contact and technical factors. Future studies with standardized protocols and predefined subgroup analyses are required to define optimal candidates and clinically meaningful endpoints, especially in the context of evolving systemic therapy.