Abstract
Hilar cholangiocarcinoma (HCCA) involves a complex anatomical region where bile ducts, arteries, and veins create a complex network. HCCA can lead to biliary strictures at the main hepatic confluence, involving the right and left radicles. Endoscopic drainage of jaundiced patients with HCCA is challenging and carries a high risk of infective complications. HCCA needs a careful multidisciplinary evaluation to assess the indication and purposes (preoperative/palliative) of the biliary drainage. Biliary drainage in HCCA needs to be planned by magnetic resonance cholangiography in order to study the biliary anatomy and perform a target drainage of the intrahepatic ducts above the malignant hilar stricture; all the opacified intrahepatic ducts above the hilar stricture must be drained to reduce septic complications. Drainage of >50% of the liver volume is important to obtain bilirubin reduction and less complications, but atrophic liver segments (identified by CT scan) do not require drainage due to the increased risk of cholangitis. When preoperative biliary drainage is planned, plastic stents must be inserted. Self-expandable metal stents are indicated for palliative purposes and should be placed only when a complete liver drainage is possible; only uncovered metal stents are indicated to drain malignant hilar strictures to avoid side-branch occlusion.
Highlights
Endoscopic drainage of hilar cholangiocarcinoma (HCCA) is a technically demanding procedure due to the tumor location which can obstruct several intrahepatic radicles at the main hepatic confluence
Among the various types of SEMS, only Uncovered Self-Expandable Metal Stents (U-SEMS) are recommended in malignant hilar stricture (MHS) because the drainage of the side branches is possible through the uncovered meshes [3, 25]
Endoscopic drainage of HCCA is challenging and its approach should be performed in referral centers where a multidisciplinary team [3] is available
Summary
Endoscopic drainage of hilar cholangiocarcinoma (HCCA) is a technically demanding procedure due to the tumor location which can obstruct several intrahepatic radicles at the main hepatic confluence. Endoscopic and percutaneous biliary drainages are the available techniques to treat jaundice secondary to HCCA. ERCP provides internal drainage by insertion of multiple plastic or metal stents, with a better effect on the quality of life compared to percutaneous drains [1, 2]. Both techniques resulted in effective jaundice resolution, and recent guidelines propose their use to be modulated according to the local expertise [3]. Infectious complications are the “Achilles’ heel” of both the endoscopic and percutaneous drainages of HCCA due to the contamination of the intrahepatic ducts above the complex malignant hilar stricture (MHS). Magnetic resonance cholangiography (MRC) can provide a detailed “road-map” to perform optimal biliary drainage of HCCA, reducing the rate of infective complications avoiding the scenario of “opacified and undrained biliary ducts.”
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