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

Abstract

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.

INTRODUCTION

Along with pancreatic cancer, cholangiocarcinoma (CCA) is the leading cause of malignant biliary obstruction (MBO) and is associated with high mortality rates.1 Surgical resection is the only potentially curative treatment; however, many patients present with advanced unresectable disease at diagnosis. Curative surgery often requires highly invasive procedures such as pancreaticoduodenectomy and hepatectomy, but many older patients and those with substantial comorbidities are not good candidates because of their limited physiological reserves. Systemic therapy is the standard of care for unresectable CCA; however, the median overall survival is approximately 1 year.2-4 These outcomes highlight the urgent need for additional effective therapeutic strategies for unresectable CCA.

Endoscopic biliary stenting is widely performed as the first-line treatment for MBO and obstructive jaundice because it is minimally invasive and effective.5 However, the stent patency is often suboptimal. Tumor progression and biliary sludge can lead to stent dysfunction and, consequently, cholangitis, recurrent jaundice, repeated hospitalizations, and frequent reinterventions, all of which substantially impair patients’ quality of life. Stent occlusion may necessitate the interruption of systemic therapy, highlighting the need for local treatment modalities that can control biliary obstruction for extended periods while maintaining a low procedural burden.

Endobiliary radiofrequency ablation (EB-RFA), which delivers local tumor ablation during endoscopic stent placement, has emerged as a novel local therapy for MBO.6,7 It was initially developed to prolong stent patency; however, accumulating data suggest that it may also improve survival in patients with extrahepatic CCA (eCCA). EB-RFA has attracted considerable interest as a feasible adjunct to biliary drainage because of the poor prognosis of eCCA and the high proportion of unresectable cases at presentation. However, this approach has not yet been fully established in routine practice, and several important questions remain unresolved.

This review aimed to highlight the clinical benefits and limitations of EB-RFA on the basis of the latest evidence and provide practical insights for patient selection, clinical decision-making, and future research.

WHAT IS EB-RFA?

EB-RFA can be performed using endoscopic or percutaneous approaches. In endoscopic practice, it is typically performed during standard endoscopic retrograde cholangiopancreatography with a dedicated RFA catheter. The catheter electrode is positioned across the target stricture under guidewire guidance after biliary cannulation, and often after endoscopic sphincterotomy. Radiofrequency energy is subsequently delivered from a generator to achieve tissue temperatures of approximately 50–100 °C and induce coagulative necrosis of the tumor tissue at the contact site.8,9

Two EB-RFA devices are currently available: the Habib Endo-HBP (Boston Scientific) and ELRA catheter (STARmed). The Habib system uses a bipolar electrode catheter and an external generator for power control. The ELRA system uses a dedicated VIVA Combo generator and incorporates temperature sensing and impedance monitoring to enable temperature-controlled ablation. The output is automatically adjusted to maintain the target temperature, and the system can reduce or stop energy delivery when tissue desiccation or inadequate contact is detected, thereby providing an additional safety mechanism. The ELRA catheter is also available with multiple electrode lengths to match the stricture length. Although the device-specific settings differ, the typical parameters are 7–10 W for 90–120 seconds,10,11 and excessive power or prolonged ablation should be avoided. For the ELRA system, the target temperature is generally set at 80 °C. Ablation can be performed by repositioning the electrode and overlapping applications or by selecting a longer electrode length with ELRA for long strictures.

EB-RFA is primarily a palliative adjunct and is not intended as a standalone therapy. Therefore, biliary stent placement is generally required for definitive drainage. Fibrotic scarring and secondary stricture formation have been reported to occur after ablation without subsequent stenting.12,13 These findings support the need for stent placement after EB-RFA. The choice between plastic stents (PSs) and self-expandable metal stents (SEMSs) is often influenced by the anticipated reablation strategy. PSs facilitate exchanges and may be advantageous if repeated EB-RFA sessions are planned at defined intervals. SEMSs are often chosen for EB-RFA as single-session adjuncts because of their potential for prolonged patency. Notably, additional EB-RFA may be feasible after SEMS placement if intra-stent tumor-related narrowing occurs. Initial drainage using PSs or endoscopic nasobiliary drainage may be prioritized for acute cholangitis or marked jaundice, followed by consideration of EB-RFA after infection and cholestasis have improved.14

EFFECT OF EB-RFA ON SURVIVAL

The potential mechanisms by which EB-RFA prolongs survival include local tumor control through coagulative necrosis and the activation of antitumor immune responses. Six randomized controlled trials (RCTs) on endoscopic EB-RFA have been reported (Table 1).15-20 Two RCTs by Yang et al.15 and Gao et al.17 focused exclusively on eCCA, whereas the others enrolled patients with MBO of heterogeneous etiologies. EB-RFA did not demonstrate a survival advantage in the four RCTs involving mixed etiologies. In contrast, Yang et al.15 reported a significantly longer mean overall survival for the EB-RFA plus stent group than for the stent-alone group (13.2±0.6 vs. 8.3±0.5 months, p<0.001). Gao et al.17 also reported a significantly longer median overall survival for the patients receiving EB-RFA (14.3 vs. 9.2 months; hazard ratio, 0.488; 95% confidence interval [CI], 0.351–0.678; p<0.001). However, the most recent RCT by Jarosova et al.,20 which included patients with pancreatic cancer and eCCA and analyzed these disease groups separately, reported no survival benefit of EB-RFA in either subgroup, including the eCCA cohort.

Table 1.

Key randomized controlled trials assessing endobiliary radiofrequency ablation for malignant biliary obstruction

Study	Year	No. of patients		Etiology	Location	EB-RFAcatheter	EB-RFAsetting	Stent type	No. of EB-RFA applications	Stent patency period(median/mean)			Survival period(median/mean)			Adverse event rate
		EB-RFA+stent	Stent							EB-RFA+stent	Stent	p-value	EB-RFA+stent	Stent	p-value	EB-RFA+stent (%)	Stent (%)	p-value
Yang et al.15	2018	32	33	Cholangiocarcinoma	Distal, hilar	Habib	7–10 W 90 s	PS	Every 3 moa)	6.8 mob)	3.4 mo	0.02	13.2 mo	8.3 mo	<0.001	6.3	9.1	0.67
Kang et al.16,c)	2021	24	24	Cholangiocarcinoma, Pancreatic cancer, Other	Distal, hilar	ELRA	7 W/10W 120 s80 ℃	UMS	1	132 day	116 day	0.440	244 d	180 d	0.281	4.2	12.5	0.609
Gao et al.17	2021	87	87	Cholangiocarcinomad)	Distal, hilar	Habib	7–10 W90 s	PS	2	3.7 mo	4.1 mo	0.674	14.3 mo	9.2 mo	<0.001	27.6(early event)	19.5(early event)	0.211
Kang et al.18	2022	15	15	Cholangiocarcinoma, Gallbladder cancer	Hilar	ELRA	7 W60–120 s80 ℃	UMS	1-2	178 day	122 day	0.154	230 day	144 day	0.643	NA	NA	NS
Albers et al.19	2022	42	44	Cholangiocarcinoma, Pancreatic cancer, Other	Distal, hilar	Habib	10 W90 s	UMS	1	NAe)	NAe)	NAe)	NAe)	NAe)	NAe)	10.5	2.3	0.18
Jarosova et al.20	2023	44	41	Cholangiocarcinoma	Distal, hilar	Habib	10 W120 s	UMS/CMS	1	NAf)	NAf)	NAf)	10.5 mo	10.6 mo	0.58	13.6	9.8	NS
		37	39	Pancreatic cancer	Distal	Habib	10 W120 s	CMS	1	NAf)	NAf)	NAf)	6.4 mo	7.7 mo	0.73	2.7	7.7	NS

EB-RFA, endobiliary radiofrequency ablation; PS, plastic stent; UMS, uncovered metal stent; NA, not applicable; NS, not significant; CMS, covered metal stent.

^a)EB-RFA was repeated if the bile duct wall thickness was >6 mm on intraductal ultrasonography performed every 3 months.

^b)Stent replacement was performed every 3 months regardless of occlusion.

^c)Cases involving percutaneous approaches were also included.

^d)Cases of ampullary cancers were also included.

^e)Stent patency and overall survival rates at 3 and 6 months did not differ significantly between the groups.

^f)Stent patency at 3, 6, 9, and 12 months did not differ significantly between the groups.

Although the results of individual trials have been inconsistent, the most recent meta-analysis of RCTs, which included 750 patients with MBO, reported that EB-RFA plus stenting significantly improved the survival of patients with eCCA relative to stenting alone (mean difference, 4.9 months; 95% CI, 4.6–5.1; p<0.001).21 This finding is biologically plausible because EB-RFA ablates the bile duct lumen and adjacent tissues. Therefore, it may be less effective for cancers such as pancreatic cancer, where biliary obstruction often results from extrinsic compression or invasion from outside the duct, and ductal ablation alone may not sufficiently modify the tumor burden.

However, these results should be interpreted with caution. Yang et al.15 and Gao et al.,17 who reported the survival benefits of EB-RFA in patients with eCCA, included patients with both locally advanced and distant metastatic disease and did not evaluate the outcomes separately based on disease stage. Abscopal effects are theoretically possible. However, the findings did not clarify whether EB-RFA, which targets the bile duct and its immediate surroundings, can provide benefits similar to those observed in patients with locally advanced disease. The Jarosova et al.’s trial20 also included both metastatic and non-metastatic cases in the eCCA cohort, and approximately 30% of the patients had stage IV disease. This may have influenced the negative results overall. In a large retrospective study, Xia et al.22 reported that prolonged survival associated with EB-RFA was observed only in patients with eCCA without distant metastasis.

EB-RFA may contribute to the prolongation of survival in patients with eCCA; however, the benefit is likely to be most relevant for patients with locally advanced disease. Future studies should investigate the relationship between disease stage and the efficacy of EB-RFA, with particular emphasis on the presence or absence of distant metastasis.

COMBINATION OF EB-RFA AND CHEMOTHERAPY

Systemic chemotherapy is the standard treatment for unresectable eCCA.1 However, the RCT by Yang et al.15 excluded patients who received chemotherapy, while that by Gao et al.17 included only a small proportion of patients undergoing chemotherapy. Therefore, further evidence of the efficacy of EB-RFA in combination with systemic therapy is essential to support its application in contemporary clinical practice.

Three studies have evaluated EB-RFA combined with chemotherapy for eCCA (Table 2).23-25 Yang et al.23 reported a longer median overall survival in patients who underwent EB-RFA plus S-1 chemotherapy than in those who underwent EB-RFA alone (16.0 vs. 11.0 months, p<0.001), suggesting an additive effect of S-1 in patients treated with EB-RFA. Notably, patients with distant metastases were excluded in this study. Gonzalez-Carmona et al.24 reported a longer median overall survival for patients who underwent EB-RFA plus gemcitabine-based chemotherapy than for those who underwent gemcitabine-based chemotherapy alone (17.3 vs. 8.6 months, p=0.004). In the subgroup analysis, the survival advantage persisted among those with non-metastatic disease (20.9 vs. 12.4 months, p=0.043) but not among those with metastatic disease (15.0 vs. 8.6 months, p=0.116). Inoue et al.25 reported a longer median overall survival for patients who underwent EB-RFA plus gemcitabine and cisplatin than for those who received gemcitabine and cisplatin alone (17.1 vs. 11.3 months, p=0.017). Similarly, the benefit was significant for those without distant metastases (23.1 vs. 16.6 months, p=0.032) but not for those with distant metastases (11.4 vs. 8.5 months, p=0.180).

Table 2.

Studies on endobiliary radiofrequency ablation and chemotherapy for extrahepatic cholangiocarcinoma

Study	Year	Study design	Treatment	No. of patients	Location	Metastatic (%)	EB-RFA catheter	Stent type	No. of EB-RFA applications	Stent patency period (median, mo)		Progression-free survival (median, mo)		Overall survival (median, mo)
Yang et al.23	2020	RCT	S-1 chemotherapy+EB-RFA	37	Distal, hilar	0	Habib	PS	3.3 (mean)	6.6	p=0.014	12	p<0.001	16.0	p<0.001
			ID-RFA	38	Distal, hilar	0	Habib	PS	2.4 (mean)	5.6		7		11.0
Gonzalez-Carmona et al.24	2022	Retrospective	GEM-based chemotherapy+EB-RFA	40	Distal, hilar	37.5	Habib	PS	1–21	NA	NA	12.9	p=0.045	17.3	p=0.004
			GEM-based chemotherapy	26	Distal, hilar	50.0	Habib	PS	-	NA		5.7		8.6
Inoue et al.25	2022	Retrospective	GEM with cisplatin+EB-RFA	25	Distal, hilar	48	Habib	UMS	1.84 (mean)	10.7	p=0.048	8.6	p=0.014	17.1	p=0.017
			GEM with cisplatin	25	Distal, hilar	60	Habib	UMS	-	5.2		5.8		11.3

EB-RFA, endobiliary radiofrequency ablation; RCT, randomized controlled trial; PS, plastic stent; ID-RFA, intraductal radiofrequency ablation; NA, not applicable; UMS, uncovered metal stent; GEM, gemcitabine; -, not applicable.

These findings are consistent with those reported by Xia et al.22 and suggest that EB-RFA may have the greatest clinical value as a local therapy for locally advanced disease without distant metastasis. However, systemic therapy for CCA is evolving rapidly, and immune checkpoint inhibitors have been widely adopted as a first-line treatment in current settings.3,4 The aforementioned studies included a few, if any, patients treated with immune checkpoint inhibitors. EB-RFA may promote the release of tumor-associated antigens after ablation and potentially enhance immune priming through antigen presentation. Emerging evidence indicates potential synergy between RFA and systemic therapy, especially immunotherapy.26,27 The systemic effects of EB-RFA, including the induction of antitumor immunity, should be investigated more thoroughly, particularly in combination with immune checkpoint blockade. These findings should be supported by mechanistic data from basic translational and clinical research.

EFFECT OF EB-RFA ON PROLONGING STENT PATENCY

PSs were used in two RCTs that enrolled only patients with eCCA. Yang et al.15 reported that the mean duration of stent patency was significantly longer with than without EB-RFA (6.8 vs. 3.4 months, p=0.02). In contrast, Gao et al.17 reported no significant difference in the median duration of stent patency with or without EB-RFA (3.7 vs. 4.1 months, p=0.674). However, interpretation of the findings obtained by Yang et al.15 is challenging because scheduled stent exchange was performed every three months, which limited the ability to evaluate the true spontaneous time to stent dysfunction. RCTs that enrolled patients with mixed etiologies used uncovered SEMSs, and none demonstrated a significant difference in stent patency between patients with and without EB-RFA.

Current RCT-level evidence does not strongly support a consistent benefit related to patency after endoscopic EB-RFA. However, many prospective and retrospective studies, including those involving percutaneous approaches, have reported prolonged patency, especially when EB-RFA is combined with uncovered SEMS.6,7,28 From a mechanistic perspective, EB-RFA is expected to reduce intraductal tumor ingrowth and may therefore have a greater impact when used with an uncovered SEMS. However, the effects on PSs remain unclear. EB-RFA may influence bile flow dynamics and local tumor burden around the PS; however, the extent to which this translates to longer patency requires further investigation.

Future studies should evaluate EB-RFA with strict standardization of the target disease, stricture location, stent type, placement technique, and procedural approach to identify scenarios wherein it confers meaningful benefits related to patency.

EB-RFA FOR OCCLUDED STENTS

On the basis of its mechanism, EB-RFA may be especially useful for treating SEMS occlusion caused by tumor ingrowth, and may facilitate recanalization. Ablation of the intra-stent ingrowth tissue can result in coagulative necrosis and sloughing, which can restore patency without additional stent placement or help extend the patency of a newly placed stent. A theoretical concern with intra-stent RFA (IS-RFA) is the excessive heating related to metal–wire interactions. However, in vivo and in vitro studies using bipolar catheters have demonstrated limited ablation effects beyond the stents.29 Another ex vivo study reported no evidence of excessive overheating or charring attributable to the presence of stent wires or structural damage to metal stents.30 These findings support the feasibility of IS-RFA as a safe adjunct in the management of SEMS occlusions.

Five studies involving at least ten cases of IS-RFA without additional stent placement have been published.31-35 Although the underlying diseases and stricture locations varied, the reported post-IS-RFA patency durations ranged from 107 to 234 days. These outcomes were comparable to or better than those reported for patency after conventional reintervention using additional stents.36-38 The avoidance of additional stent placement may also offer potential cost advantages.

Three comparative studies31,35,39 of IS-RFA for occluded SEMS have been published (Table 3). Kadayifci et al.31 reported that the mean stent patency after reintervention was significantly longer with IS-RFA than with PS placement (119.5 vs. 65.3 days, p=0.03). In their evaluation of reintervention for occluded SEMS, Park et al.39 reported a longer median time to recurrent biliary obstruction for IS-RFA plus uncovered SEMS than for uncovered SEMS alone (117 vs. 82.5 days, p=0.029). In their study of ingrowth occlusion after bilateral SEMS placement for hilar strictures, Inoue et al.35 reported a significantly longer median time to recurrent biliary obstruction in the IS-RFA group than in the PS group (163 vs. 89 days, p=0.015). The IS-RFA group also underwent fewer reintervention procedures (1.4 vs. 2.5, p=0.038).

Table 3.

Studies on endobiliary radiofrequency ablation for the treatment of occluded metal stents

Study	Year	Study design	No. of patients		Etiology	Stricture location	EB-RFA catheter	RFA settings	Stent patency period after reintervention (median/mean)			Adverse event rate
			EB-RFA	Control					EB-RFA (day)	Control (day)	p-value	EB-RFA (%)	Control	p-value
Kadayifci et al.31	2016	Retrospective	25	25 (PS)	Cholangiocarcinoma, pancreatic cancer, other	-	Habib	10 W 90 s	119.5	65.3	0.03	0 (significant event)	0 (significant event)	NS
Park et al.39	2023	Retrospective	9 (with UMS)a)	9 (UMS alone)a)	Cholangiocarcinoma, pancreatic cancer	Distal	ELRA	80 ℃ 120 s	117	82.5	0.029	0 (significant event)	0 (significant event)	NS
Inoue et al.35	2025	Retrospective	40a)	40 (PS)a)	Cholangiocarcinoma, other	Hilar	Habib	10 W 90 s	163	89	0.015	7.5	5	NS

EB-RFA, endobiliary radiofrequency ablation; NS, not significant; PS, plastic stent; UMS, uncovered metal stent; -, not applicable.

^a)These are based on the propensity score–matched cohort.

However, the clinical success rates of IS-RFA are suboptimal. Some studies have reported clinical success rates of 56%,31 70.3%,35 and 71.4%.32 Insufficient electrode contact with irregular, non-concentric ingrowth tissue, which leads to incomplete ablation, is a possible explanation.6 Animal studies have also reported reduced current density and ablation efficacy due to contact between the electrodes and stent wires.30 Therefore, improving clinical success is essential before IS-RFA can be widely adopted as a standard reintervention strategy. Newer catheters, such as ELRA, have a mechanism that automatically stops energy delivery when a short circuit occurs due to contact with stent wires. This feature allows operators to slightly reposition the catheter and repeat ablation, which may help achieve more consistent efficacy during IS-RFA.39

ADVERSE EVENTS AND SAFETY OF EB-RFA

The adverse events associated with EB-RFA include cholangitis, pancreatitis, cholecystitis, hemobilia, bleeding, liver abscess, perforation, and vascular injury.6 Overall, EB-RFA is generally regarded as a feasible and relatively safe procedure, and most of the reported adverse events are pancreatobiliary in nature. In prior comparative studies, the overall adverse event rates did not differ significantly between patients treated with and without EB-RFA.6,15-20 However, rare but serious events have been reported, including fatal bleeding,40 pseudoaneurysm,41 partial liver infarction,42 biliary perforation,43 and hyperkalemia.44

One RCT by Gao et al.17 also showed that although the overall adverse event rate was not significantly different between the groups, cholecystitis occurred significantly more often in the EB-RFA group than in the stent-alone group (10.3% vs. 0%, p=0.003). The authors suggested that ablation performed near the cystic duct orifice may induce edema or thermal injury around the ductal opening, thereby increasing the risk of cholecystitis. This finding indicates that even when the overall safety profile appears acceptable, the anatomical location of the target stricture and the extent of ablation should receive attention.

Overall, the current evidence suggests that EB-RFA can be performed with an acceptable safety profile; however, clinicians should be aware of the possibility of uncommon yet potentially severe adverse events. Further studies with standardized definitions and detailed reporting of adverse events are required to better define the safety profile of EB-RFA.

FUTURE PROSPECTS OF EB-RFA

As summarized above, evidence supporting EB-RFA, especially for eCCA without distant metastasis, has recently increased. However, the evidence base remains insufficient, and several key issues require clarification.

First, additional high-quality evidence and robust subgroup analyses are required. The existing data are inconsistent, and additional international multicenter RCTs and meta-analyses integrating these data are required. Future studies should predefine subgroup analyses based on clinically relevant factors to identify the patient populations that benefit the most. Trials involving well-defined populations, such as patients with locally advanced eCCA scheduled for systemic therapy, and studies incorporating prospective assessments of quality of life and cost-effectiveness would help establish the clinical role of EB-RFA more clearly.

Second, systemic therapy for unresectable biliary tract cancer has changed substantially, especially with the widespread adoption of immune checkpoint inhibitors in first-line regimens.3,4 Preliminary observations suggest that EB-RFA may have synergistic effects when combined with systemic therapy. EB-RFA-induced antigen release and immune activation may enhance systemic antitumor effects, even in metastatic diseases.27,45 However, these effects are still speculative, and well-designed clinical trials are required to validate them. The role of EB-RFA in the era of immunotherapy may become clearer after the completion of ongoing clinical studies, including the ACTICCA-2 trial (NCT06175845) and the BRAVE trial (NCT07235007). The BRAVE trial is our RCT evaluating EB-RFA plus durvalumab, gemcitabine, and cisplatin for unresectable eCCA.

Third, the optimal number and timing of EB-RFA sessions remain uncertain. Published studies have described various protocols, including single-session treatment, repeated ablation at approximately three-month intervals, and two planned sessions separated by several months. The differences among these protocols are likely to influence outcomes and are closely linked to stent-selection strategies. In addition, the anatomical differences between hilar and distal MBO may require different procedural settings, potentially including different power or temperature parameters. However, this issue needs to be evaluated systematically. RCTs with standardized ablation schedules and settings that evaluate both overall survival and stent-related outcomes are needed.

Finally, technological innovation and evaluation of expanded indications are crucial. Temperature-controlled systems have improved the uniformity of energy delivery; however, further advances are required, including broader electrode size options and improved contact and targeting. The existing bipolar catheters require adequate tissue contact at multiple electrodes and effective ablation may not be achieved for certain lesion morphologies.6,46 Future approaches may include cholangioscopy-guided targeted ablation,47 specialized catheter shapes designed to improve contact,48 and balloon-based RFA systems,49 some of which have been explored in preclinical studies. Comparative or combined strategies with other local therapies such as photodynamic therapy,50 microwave ablation,51 and irreversible electroporation,52 also represent attractive research directions.

CONCLUSIONS

EB-RFA has evolved into a novel local therapy for MBO. Current evidence suggests that with appropriate patient selection, EB-RFA may provide meaningful clinical benefits, including delayed recurrent biliary obstruction and possible prolongation of survival. However, recent large trials have also reported neutral results, highlighting the need to better define the populations that are most likely to benefit. Available data indicate that patients with eCCA confined to locoregional disease without distant metastasis are the most plausible candidates for the benefits of EB-RFA, whereas the contribution of EB-RFA may be limited in patients with advanced systemic disease. However, combination strategies using contemporary systemic therapies, including immunotherapy, remain an area of active interest.

EB-RFA should be viewed as an adjunct procedure performed in conjunction with biliary drainage rather than as a curative modality. When used appropriately, it can improve the quality of biliary decompression and potentially enhance the patient’s quality of life and outcomes. With continued research to refine the indications, protocols, and device technology, EB-RFA may become an established component of care for patients with eCCA and MBO.