Endoscopic or percutaneous approach for advanced biliary stenoses at the hepatic hilum?

Abstract

To the Editor: We read with interest the study by Paik et al1Paik W.H. Park Y.S. Hwang J. et al.Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach.Gastrointest Endosc. 2009; 69: 55-62Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar that compared the outcomes of percutaneous and endoscopic approaches of biliary stenting in advanced hilar cholangiocarcinoma (Bismuth type III and IV) in which the investigators concluded that percutaneous self-expanding metallic stents may be preferable for initial biliary drainage in these patients, given a higher initial success rate (92.7% vs 77.3%, respectively, P < .049) and low level of procedure-related cholangitis (29.5% vs 22.0%, respectively, P = not significant). These conclusions are further supported by the evidence that median survival of patients in whom biliary drainage was initially successful was much longer than that of those who had a failed drainage (8.7 months vs 1.8 months, respectively, P < .001). The outcomes of the present study, however, are not consistent with previous reports that show that initial complication rates after endoscopic stent placement in malignant hilar stenoses are less than those after percutaneous placement.2Born P. Rösch T. Bruhl K. et al.Long-term outcome in patients with advanced hilar bile duct tumors undergoing palliative endoscopic or percutaneous drainage.Z Gastroenterol. 2000; 38: 483-489Crossref PubMed Scopus (48) Google Scholar To draw firm conclusions from the study by Paik et al1Paik W.H. Park Y.S. Hwang J. et al.Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach.Gastrointest Endosc. 2009; 69: 55-62Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar we would like to ask the investigators to provide further data about the following important points: (a) whether the approach to these patients was aimed toward a unilateral or a bilateral drainage and whether this was successfully achieved and (b) how the patients with failed initial biliary drainage were managed. Recent reports show that endoscopic stent insertion should be successfully achieved in more than 90% of patients when the unilateral drainage is used to drain a hilar obstruction, with a risk of procedure-related cholangitis of 5% to 10%.3Cheng J.L. Bruno M.J. Bergman J.J. et al.Endoscopic palliation of patients with biliary obstruction caused by nonresectable hilar cholangiocarcinoma: efficacy of self-expandable metallic Wallstents.Gastrointest Endosc. 2002; 56: 33-39Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar, 4Freeman M.L. Overby C. Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents.Gastrointest Endosc. 2003; 58: 41-49Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 5De Palma G.D. Pezzullo A. Rega M. et al.Unilateral placement of metallic stents for malignant hilar obstruction: a prospective study.Gastrointest Endosc. 2003; 58: 50-53Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar The risk of cholangitis after the endoscopic approach mainly pertains to the failure to insert a stent into an obstructed hepatic lobe that is filled with contrast.6Chang W. Kortan P. Haber G. Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage.Gastrointest Endosc. 1998; 47: 354-362Abstract Full Text Full Text PDF PubMed Scopus (363) Google Scholar Generally, if both lobes are imaged with contrast during cholangiography, bilateral stenting reduces the potential sequelae of cholangitis in contaminated but undrained areas. If contrast does not contaminate both sides, then unilateral stenting should be sufficient.6Chang W. Kortan P. Haber G. Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage.Gastrointest Endosc. 1998; 47: 354-362Abstract Full Text Full Text PDF PubMed Scopus (363) Google Scholar, 7De Palma G.D. Galloro G. Iovino P. et al.Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction. Results of a prospective, randomized, and controlled study.Gastrointest Endosc. 2001; 53: 547-553Abstract Full Text Full Text PDF PubMed Scopus (357) Google Scholar If endoscopic placement fails, then a promptly performed percutaneous drainage can lower the risk of acute cholangitis. In conclusion, we believe that endoscopic stent placement should now be accepted as the first-line palliative treatment for patients with advanced malignant hilar strictures, whereas, the percutaneous approach should be reserved for those patients who had a failed endoscopic stent insertion.