Strategy for ERCP stenting in cholangiocarcinoma

Abstract

Considering the steadily growing incidence of cholangiocarcinoma (CCA) worldwide, there is a constant need to re-evaluate and re-think its pathophysiology, diagnostic modalities, and mostly important, its treatment. No matter the histopathological appearance, endoscopic procedures - mainly Endoscopic Retrograde Cholangiopancreatography (ERCP) with stenting - are often used in the treatment of CCA complications, such as biliary obstruction when biliary drainage is indicated. Indications for preoperative biliary drainage in surgical cases are adjusted to each patient’s status. On the contrary, palliative drainage is the first option for relieving symptoms and improving the quality of life in the context of locally advanced and unresectable CCA. Further, concern about stenting techniques depends on the stricture location: Bismuth-Corlette types I and II are usually endoscopically drained with one stent placed in biliary tract, while for types III and IV, even bilateral stenting may prove inadequate. Stents used in ERCP are either plastic or self-expandable metallic stents (SEMS). Though plastic stents show some advantages over SEMS in terms of removability and possibility to adapt to a biliary tree which allows potential reinterventions, SEMS are better in terms of patency, lower complications number, and success of drainage. Besides ERCP, echo-endoscopic drainage is also an option, especially when ERCP approach has not yielded a successful drainage. The aim of this study was to show the potential of ERCP stenting in CCA treatment, its possible pitfalls, and the need to consider multiple levels of ERCP-related care.