Abstract
Malignant hilar biliary obstruction (HBO) represents a complex clinical condition in terms of diagnosis, surgical and medical treatment, endoscopic approach, and palliation. The main etiology of malignant HBO is hilar cholangiocarcinoma that is considered an aggressive biliary tract’s cancer and has still today a poor prognosis. Endoscopy plays a crucial role in malignant HBO from the diagnosis to the palliation. This technique allows the collection of cytological or histological samples, direct visualization of the suspect malignant tissue, and an echoendoscopic evaluation of the primary tumor and its locoregional staging. Because obstructive jaundice is the most common clinical presentation of malignant HBO, endoscopic biliary drainage, when indicated, is the preferred treatment over the percutaneous approach. Several endoscopic techniques are today available for both the diagnosis and the treatment of biliary obstruction. The choice among them can differ for each clinical scenario. In fact, a personalized endoscopic approach is mandatory in order to perform the proper procedure in the singular patient.
Highlights
Published: 29 January 2021The management of malignant hilar biliary obstruction (HBO) is still today a medical challenge in terms of diagnosis, treatment alternatives, and palliation options
Both brush cytology and forceps biopsy are burdened by a low negative predictive value, when the report is negative for cancer but the radiological and clinical suspicious is high, other techniques should be applied to obtain a proper pathological analysis
One of the main causes of death after right hepatectomy is liver failure, and it has been shown that it is significantly more frequent in patients who did not undergo preoperative biliary drainage (PBD) [34]. This difference can be attributed to the higher volume of parenchyma loss in the right hepatectomy when compared to the left one, the quantification of future liver remnant (FLR) volume is essential to indicate whether PBD should be performed [39]
Summary
The management of malignant hilar biliary obstruction (HBO) is still today a medical challenge in terms of diagnosis, treatment alternatives, and palliation options. The complexity of malignant HBO makes each patient a singular case requiring a personalized approach from the diagnosis to the final treatment. In this setting, a multidisciplinary is mandatory with the involvement of surgeons, endoscopists, interventional radiologists, and oncologists in order to find the best approach that properly fits with the patients’ characteristics. The aim of this study was to perform a review of the current literature in order to define the current role of endoscopy in diagnosis, biliary drainage, and palliation of malignant HBO and their application in the various clinical settings, and to assess the role of personalized endoscopy in the treatment of complex malignant hilar biliary strictures
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