Endoscopic Ablation of Perihilar Biliary Malignancies

Abstract

AbstractCholangiocarcinoma (CCA) is a malignancy arising from biliary epithelial cells and is subdivided based on the location within the biliary tree. The treatment of CCA differs based on the anatomical involvement within the biliary tree. Perihilar CCA (pCCA) arises between the cystic duct and the secondary branches of the right and left hepatic ducts. Surgical resection and liver transplantation offer the only hope for cure in pCCA, but, unfortunately, more than 80% of patients are considered surgically unresectable at the time of diagnosis resulting in a limited overall life expectancy of less than 1 year. For patients with surgically unresectable pCCA, treatment options are limited and include chemotherapy/chemoradiotherapy and biliary drainage via endoscopic stenting or percutaneous drainage with minimal overall survival benefits. However, endobiliary ablation options like photodynamic therapy (PDT), radiofrequency ablation (RFA), and, to a lesser degree, intraluminal brachytherapy have shown improvements in overall survival and improvements in stent patency and now should be considered for all cases of surgically unresectable pCCA. In fact, the 2023 American College of Gastroenterology (ACG) Clinical Guidelines on the diagnosis and management of biliary strictures recommend endobiliary ablation (PDT or RFA) for patients with surgically unresectable pCCA rather than stenting alone.