Curr Gastroenterol Rep (2015) 17:3 DOI 10.1007/s11894-014-0426-9
PANCREAS AND BILIARY TRACT (O HALUSZKA, SECTION EDITOR)
Endoscopic Treatment of Malignant Biliary Strictures Tarun Rustagi & Priya A. Jamidar
# Springer Science+Business Media New York 2015
Abstract Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.
Keywords Pancreatic cancer . Distal . Hilar . SEMS . Preoperative . Drainage . RFA . Photodynamic therapy . PDT . Covered . Plastic stents . Cholangiocarcinoma
Introduction Biliary strictures can be caused by various benign and malignant etiologies. Several primary or secondary (metastatic) malignancies can involve the extrahepatic or intrahepatic biliary system leading to malignant biliary strictures. The common causes of malignant biliary strictures are shown in Table 1. Pancreatic cancer accounts for the majority of malignant distal biliary strictures, whereas cholangiocarcinoma is the most common etiology for malignant hilar strictures. The goal of intervention is to relieve biliary obstruction to prevent or treat complications of cholestasis such as cholangitis and secondary biliary cirrhosis. The most common indication for biliary decompression in malignant biliary strictures is palliation, followed by preoperative drainage in patients with resectable or borderline resectable disease undergoing neoadjuvant therapy. Endoscopic decompression, primarily through endobiliary stenting, is the preferred therapeutic option offering lower overall cost, shorter hospitalization, and lower morbidity when compared with surgical intervention. The type of stent used depends on multiple factors including suspected vs. histologically proven malignancy, location and length of the stricture as well as potential resectability, life expectancy, and consideration of adjuvant therapy. In addition, endoscopic ablative therapies such as PDT and RFA are emerging as potential adjuvant palliative treatments. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.
This article is part of the Topical Collection on Pancreas and Biliary Tract T. Rustagi : P. A. Jamidar (*) Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT 06520, USA e-mail: [email protected] T. Rustagi e-mail: [email protected]
Preoperative Biliary Drainage: Resectable, Borderline Resectable, and Unknown Resectable The role of preoperative biliary drainage (PBD) in patients with obstructive jaundice due to a proximal or distal bile duct/pancreatic head malignancy is controversial. PBD was
3
Curr Gastroenterol Rep (2015) 17:3
Page 2 of 8
Table 1 Causes of malignant biliary strictures
Extrahepatic
Hilar region
Intrahepatic
Pancreatic cancer
Cholangiocarcinoma
Cholangiocarcinoma
Cholangiocarcinoma
Gallbladder malignancy
Hepatocellular carcinoma
Ampullary neoplasia
Porta-hepatis malignant
Metastatic disease
Gallbladder malignancy
Lymphadenopathy
Metastatic disease
initially introduced because experimental studies found significant reductions in mortality by restoring liver function and nutritional status, reducing systemic endotoxemia and cytokine release with improvement in immune response [1–6]. In addition, the resulting delay from stent insertion does not preclude a future curative pancreatoduodenectomy and has no effect on postoperative survival [7, 8]. Most human studies, however, have failed to demonstrate any clinical benefit with PBD. In a large, multicenter trial including 202 patients with resectable pancreatic cancer, randomizing either to surgery within 1 week of diagnosis or PBD for 4–6 weeks followed by surgery showed no difference in mortality, although significantly more serious complications (74 vs. 39 %; P
PANCREAS AND BILIARY TRACT (O HALUSZKA, SECTION EDITOR)
Endoscopic Treatment of Malignant Biliary Strictures Tarun Rustagi & Priya A. Jamidar
# Springer Science+Business Media New York 2015
Abstract Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.
Keywords Pancreatic cancer . Distal . Hilar . SEMS . Preoperative . Drainage . RFA . Photodynamic therapy . PDT . Covered . Plastic stents . Cholangiocarcinoma
Introduction Biliary strictures can be caused by various benign and malignant etiologies. Several primary or secondary (metastatic) malignancies can involve the extrahepatic or intrahepatic biliary system leading to malignant biliary strictures. The common causes of malignant biliary strictures are shown in Table 1. Pancreatic cancer accounts for the majority of malignant distal biliary strictures, whereas cholangiocarcinoma is the most common etiology for malignant hilar strictures. The goal of intervention is to relieve biliary obstruction to prevent or treat complications of cholestasis such as cholangitis and secondary biliary cirrhosis. The most common indication for biliary decompression in malignant biliary strictures is palliation, followed by preoperative drainage in patients with resectable or borderline resectable disease undergoing neoadjuvant therapy. Endoscopic decompression, primarily through endobiliary stenting, is the preferred therapeutic option offering lower overall cost, shorter hospitalization, and lower morbidity when compared with surgical intervention. The type of stent used depends on multiple factors including suspected vs. histologically proven malignancy, location and length of the stricture as well as potential resectability, life expectancy, and consideration of adjuvant therapy. In addition, endoscopic ablative therapies such as PDT and RFA are emerging as potential adjuvant palliative treatments. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.
This article is part of the Topical Collection on Pancreas and Biliary Tract T. Rustagi : P. A. Jamidar (*) Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT 06520, USA e-mail: [email protected] T. Rustagi e-mail: [email protected]
Preoperative Biliary Drainage: Resectable, Borderline Resectable, and Unknown Resectable The role of preoperative biliary drainage (PBD) in patients with obstructive jaundice due to a proximal or distal bile duct/pancreatic head malignancy is controversial. PBD was
3
Curr Gastroenterol Rep (2015) 17:3
Page 2 of 8
Table 1 Causes of malignant biliary strictures
Extrahepatic
Hilar region
Intrahepatic
Pancreatic cancer
Cholangiocarcinoma
Cholangiocarcinoma
Cholangiocarcinoma
Gallbladder malignancy
Hepatocellular carcinoma
Ampullary neoplasia
Porta-hepatis malignant
Metastatic disease
Gallbladder malignancy
Lymphadenopathy
Metastatic disease
initially introduced because experimental studies found significant reductions in mortality by restoring liver function and nutritional status, reducing systemic endotoxemia and cytokine release with improvement in immune response [1–6]. In addition, the resulting delay from stent insertion does not preclude a future curative pancreatoduodenectomy and has no effect on postoperative survival [7, 8]. Most human studies, however, have failed to demonstrate any clinical benefit with PBD. In a large, multicenter trial including 202 patients with resectable pancreatic cancer, randomizing either to surgery within 1 week of diagnosis or PBD for 4–6 weeks followed by surgery showed no difference in mortality, although significantly more serious complications (74 vs. 39 %; P
