Abstract
<jats:p>Background/Objectives: Malignant distal biliary obstruction (MDBO) is a frequent complication of pancreatic cancer and often leads to obstructive jaundice, impaired liver function, and delayed oncologic treatment. Endoscopic biliary drainage using endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the standard minimally invasive approach for restoring biliary flow. However, clinical outcomes and complication rates vary across studies depending on stent design, placement technique, and patient characteristics. The aim of this systematic review was to evaluate the clinical outcomes and complications associated with endoscopic biliary stenting in pancreatic cancer-related MDBO. Methods: A systematic literature search was performed in PubMed/MEDLINE, ScienceDirect, Web of Science, and the Cochrane Library for studies published between January 2016 and January 2026. Studies evaluating ERCP-guided biliary stenting in adult patients with pancreatic cancer-related malignant distal biliary obstruction were included. Study selection followed PRISMA 2020 guidelines, and methodological quality was assessed using the Newcastle–Ottawa Scale. Clinical outcomes including technical success, clinical success, stent patency, recurrent biliary obstruction, and procedure-related complications were analyzed. Results: Eighteen studies involving a total of 3291 patients were included in the qualitative synthesis. Technical success rates were consistently high, reaching up to 100% in several studies, while clinical success rates generally exceeded 90%. Median time to recurrent biliary obstruction ranged from approximately 102 to 541 days depending on stent type and placement technique. Recurrent biliary obstruction was the most frequently reported complication, occurring in 30.7% of patients. Stent migration occurred in 14.9% of cases, while post-ERCP pancreatitis was reported in approximately 4.2% of patients. Several studies demonstrated longer patency with self-expandable metal stents compared with plastic stents. Conclusions: Endoscopic biliary stenting performed during ERCP is an effective and safe strategy for the management of malignant distal biliary obstruction in pancreatic cancer. Self-expandable metal stents provide more durable biliary drainage and reduce the need for repeat interventions. Nevertheless, recurrent biliary obstruction remains a common limitation, highlighting the need for further improvements in stent technology and optimized placement strategies.</jats:p>