Malignant biliary obstruction: From palliation to treatment

Abstract

Malignant obstruction of the bile duct from cholangiocarcinoma, pancreatic adenocarcinoma, or other tumors is a common problem which may cause debilitating symptoms and increase the risk of subsequent surgery. The optimal treatment - including the decision whether to treat prior to resection - depends on the type of malignancy, as well as the stage of disease. Preoperative biliary drainage is generally discouraged due to the risk of infectious complications, though some situations may benefit. Patients who require neoadjuvant therapy will require decompression for the prolonged period until attempted surgical cure. For pancreatic cancer patients, self-expanding metallic stents are superior to plastic stents for achieving lasting decompression without stent occlusion. For cholangiocarcinoma patients, treatment with percutaneous methods or nasobiliary drainage may be superior to endoscopic stent placement, with less risk of infectious complications or failure. For patients of either malignancy who have advanced disease with palliative goals only, the choice of stent for endoscopic decompression depends on estimated survival, with plastic stents favored for survival of < 4 mo. New endoscopic techniques may actually extend stent patency and patient survival for these patients by achieving local control of the obstructing tumor. Both photodynamic therapy and radiofrequency ablation may play a role in extending survival of patients with malignant biliary obstruction.

Keywords: Catheter ablation; Cholangiocarcinoma; Extrahepatic cholestasis; Pancreatic neoplasms; Stents.

Figure 1

Algorithm for treatment of distal malignant biliary obstruction based on disease stage. Patients who are not candidates for ERCP with stent placement may undergo EUS-BD or percutaneous drainage. Adapted from Boulay BR, Parepally M. World J Gastroenterol 2014; 20: 9345-9353. SEMS: Self-expanding metallic stent; ERCP: Endoscopic retrograde cholangiography; EUS-BD: Endoscopic ultrasound-guided biliary drainage.

Figure 2

Algorithm for treatment of hilar malignant biliary obstruction. PBD is an individualized decision based on local expertise. PTBD: Percutaneous transhepatic biliary drainage; SEMS: Self-expanding metallic stent; PBD: Preoperative biliary drainage.