Expandable Metal Stents for Malignant Hilar Biliary Obstruction

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Endoscopic versus percutaneous transhepatic approach

Endoscopic and percutaneous techniques allow access to hilar stenoses for subsequent diagnostic and therapeutic procedures. Both methods have advantages and disadvantages. Prophylactic administration of antibiotics is mandatory before any intervention for hilar decompression because of an increased risk of cholangitis, particularly in case of incomplete drainage.

Endoscopic retrograde cholangiopancreatography (ERCP) is recommended as the first-line drainage procedure for the palliation of

Types of stent

Biliary decompression of hilar obstruction can be obtained with plastic stents or SEMS. Straight, slightly curved, or pigtail stents are the most commonly used types of plastic endoprostheses. They are less expensive than metal stents but have a higher risk of an early occlusion with the consequence of recurrent jaundice and cholangitis. If signs of cholangitis develop, stent replacement is necessary to avoid the development of life-threatening sepsis.42 Stent occlusion is associated with

Techniques of implantation and clinical results

There is controversy as to whether complete drainage of hilar obstruction is necessary. Preoperative MRCP should be performed in all patients with suspected proximal biliary stenoses. MRCP and magnetic resonance imaging (MRI) of the liver allow classification of hilar stenoses according to the Bismuth categories and determination of the volume of obstructed liver segments. In addition, it provides further information on tumor staging in terms of metastases and tumor involvement of vessels. This

Complications and management

ERCP may cause complications related to the biliary access and endoscopic sphincterotomy, which is usually required for diagnostic measures and stent placement, particularly for positioning more than 1 stent. However, early complications are mainly caused by cholangitis, with an incidence of 10% to 30%.37, 49, 63 A significantly higher risk occurs if opacified obstructed segments cannot be subsequently drained.41 Because of an increased mortality, a rescue percutaneous transhepatic approach

Alternative therapy

If preoperative staging indicates tumor resectability, a complete resection offers the only chance for cure of CCA (Boxes 3 and 4). It is technically demanding to achieve curative resection with histologically negative margins. This is because of the anatomic location of the tumor at the biliary confluence and the vascular supply of the liver. Furthermore, the tumor has the tendency to grow into the surrounding perineural and hepatic tissue. Because only very poor survival rates after liver

Summary

Most malignant hilar stenoses are caused by CCA. Most patients present at an advanced stage of disease with no option for a potentially curative surgical resection of the tumor. Therefore palliative treatment plays a major role in the management of HCCA. Effective biliary decompression is of great importance for improvement in liver function and treatment of associated cholangitis. Interdisciplinary planning of endoscopic and/or percutaneous transhepatic interventions should be done with

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