Self-Expanding Metallic Stents for Malignant Hilar Biliary Obstruction

Abstract

There is substantial controversy regarding the optimal method for diagnosis and palliation of jaundice with respect to timing, route, method, and extent of drainage of hilar tumors. Traditional methods of endoscopic retrograde cholangiography (ERCP) and drainage using standard opacification techniques and plastic stents have generally resulted in poor outcomes with ineffective palliation and frequent complications, especially cholangitis. Optimal results of diagnosis, staging, curative resection, and/or palliation are achieved using an advanced multidisciplinary team approach that incorporates maximal noninvasive imaging before any intervention is undertaken, especially MRCP. Hilar tumors can be classified into three main types based on the origin of the tumor: primary, local extension, or metastasis. Most patients are not candidates for resection, placing a premium on effective palliative drainage. ERCP is the primary modality for drainage. Ineffective drainage, regardless of route, and associated cholangitis are major determinants of early mortality. Increasing evidence suggests that metallic stents are superior to plastic stents for palliation of hilar malignant biliary obstruction in most circumstances, if optimally positioned. It remains unclear in which circumstances a single stent is sufficient for effective palliation and avoidance of cholangitis in excluded segments. With improvements in technology of guidewires, catheters, and particularly of metallic stents and their delivery systems, placement of more than one stent is technically feasible in the majority of circumstances.