Biliary Decompression Research Articles

Endoscopic Management of Biliary Disorders: Diagnosis and Therapy.

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic and therapeutic tool to a predominantly therapeutic tool. There is a limited role for diagnostic ERCP with widespread availability of magnetic resonance cholangiopancreatography and endoscopic ultrasound (EUS). Since its introduction, EUS evolved from a diagnostic imaging modality to one with combined diagnostic and therapeutic capabilities. Currently, ERCP remains the standard of care for biliary decompression. In future, it is possible that EUS guided transmural biliary drainage may replace ERCP for certain indications. Given the risk of adverse events related with these more invasive endoscopic procedures, a multidisciplinary team-based approach is recommended.

Practical applications and learning curve for EUS-guided hepaticoenterostomy: results of a large single-center US retrospective analysis.

Background and study aims Endoscopic ultrasound-guided hepaticoenterostomy (EUS-HE) is an effective method of endoscopic biliary drainage in cases where endoscopic retrograde cholangiopancreatography has failed or is deemed impossible. Indications for EUS-HE have expanded, resulting in increased interest by endoscopists to learn the procedure; however, few data exist on breadth of application or experience needed to develop proficiency. We describe utilization of EUS-HE for biliary decompression at a large tertiary referral center along with procedural learning curve. Patients and methods Retrospective evaluation of 60 consecutive patients who underwent attempted EUS-HE by one endoscopist from February 2016 through June 2018. Procedures were divided into chronological and summative experience quartiles. We compared procedural success rate, procedural utilization, and procedure duration over time. Results Sixty patients underwent attempted EUS-HE during the study period: 35 with surgically altered anatomy, 23 with malignant biliary obstruction, 35 outpatients, 35 females; median age, 66 years. The procedure was technically successful in 53 patients. Success rates by summative experience quartile were 80 %, 80 %, 93.3 % and 100 % respectively. Beginning at patient number 40, the remaining cases had a success rate of 100 %. Utilization increased from eight cases in the first chronological quartile to 28 in the fourth. There was no significant reduction in procedure duration over time. Conclusion For an experienced endoscopist, EUS-HE could be performed effectively and safely after the experience of 40 cases. Limitations of this study include a single endoscopist and heterogeneous patient population with variable anatomy that may affect procedural success. Future studies should include data from multiple centers and endoscopists.

PS-210-Repeated hepatic regeneration stimuli promoted biliary decompression via formation of extrahepatic biliary collaterals

PS-210-Repeated hepatic regeneration stimuli promoted biliary decompression via formation of extrahepatic biliary collaterals

AB009. S2-3. Surgical approach to hilar cholangiocarcinoma

: Hilar cholangiocarcinoma account for 50–70% of all biliary tract malignancies. While surgical resection is the mainstay of curative intent therapy for any cholangiocarcinoma, tumors in the hilar location present the most technically challenging because of the close relationship between biliary and vascular structures at this location. Patients who present with local disease can be treated with surgical therapy, either resection or transplant. Transplant is typically reserved for locally unresectable tumors often in the setting of underlying hepatic dysfunction. Retrospective data suggest that survival is similar between resection and transplant. Given the challenges with organ shortage and complex and often restrictive eligibility criteria, hilar cholangiocarcinoma should be treated the R0 resection when possible. Surgical resection for hilar cholangiocarcinoma results in 5-year survival rates range between 30–45%, with median survival ranging from 30–60 months. Favorable long-term outcome requires low perioperative complications and complete R0 resection, often best performed at high-volume specialty referral centers. Preoperative assessment, including high-quality imaging is important to determine local extent and determine risk factors for post-hepatectomy liver failure. Preoperative biliary decompression is often needed to correct hyperbilirubinemia and reduce postoperative morbidity. The operative approach necessitates surgical skills focused on determining resectability intraoperatively, performing a hemihepatectomy with en bloc resection of the extrahepatic bile duct, portal lymphadenectomy, and biliary reconstruction. Staging laparoscopy can be used selectively when there is concern for advanced disease on preoperative imaging. In some cases, main portal vein resection and reconstruction can be performed. Such cases can be associated with higher morbidity and should be done in high-volume centers with surgeons with experience in microsurgical vascular techniques. The role of adjuvant therapy for this disease has been controversial. High-risk patients such as those with positive margins or lymph node metastases may benefit from chemoradiation. More recently, randomized data support the use of adjuvant capecitabine.

Therapy for hilar cholangiocarcinoma

Purpose: to present different modalities of biliary decompression and specific antitumor treatment of hilar cholangiocarcinoma (Klatkin tumor). material and methods. The review was based on 318 publications available from Pubmed, Medline, Elibrary, etc. in the interval time between 19212018. results. Hilar cholangiocarcinoma is a rare hepatobiliary malignancy with dismal prognosis demonstrating slow periductal infiltrative growth, late metastasis and causing death mainly due to local complications. Percutaneous transhepatic biliary drainage (PTBD) is the optimal way of biliary decompression for malignant hilar strictures nowadays. PTBD is the safest, technically accessible technique with reproducible results. Transpapillary decompression in Klatskin tumor patients is technically feasible in 40 % of cases only. Biliary resection accompanied by major hepatectomy is considered the only curative modality to the date, but its results aren’t satisfactory a well as the majority of patients aren’t seemed the surgical candidates. Thus the locoregional technologies, i.e. radiation therapy, radiofrequency ablation and photodynamic therapy (PDT), are widely spread. PDT should be preferred over other local modalities due to safety, efficiency, possibility of reinterventions, technical and economic accessibility. conclusion. Modern approaches to the management of Klatskin tumor do not differ much from the those proposed by the first researchers in the middle of the xxth century and comes down to the biliary stricture dilatation and the sustenance of the normal bile passage as long as possible. However, despite the strategic stagnation, significant tactical successes were achieved thus allowing significant prolongation of survival in previously considered incurable patients.

Radiofrequency and malignant biliary strictures: An update.

Malignant biliary strictures are usually linked to different types of tumors, mainly cholangiocarcinoma, pancreatic and hepatocellular carcinomas. Palliative measures are usually adopted in patients with nonresectable or borderline resectable biliary disease. Stent placement is a well-known and established treatment in patients with unresectable malignancy. Intraductal radiofrequency ablation (RFA) represents a procedure that involves the use of a biliary catheter device, via an endoscopic approach. Indications for biliary RFA described in literature are: Palliative treatment of malignant biliary strictures, avoiding stent occlusion, ablating ingrowth of blocked metal stents, prolonging stent patency, ablating residual adenomatous tissue after endoscopic ampullectomy. In this mini-review we addressed focus on technical success defined as deployment of the RF catheter, virtually succeeded in all patients included in the studies. About efficacy, three main outcome measures have been contemplated: Biliary decompression and stent patency, survival. Existing studies suggest a beneficial effect on survival and stent patency with RFA, but current impression is limited because most of studies have been performed using a retrospective design, on diminutive and dissimilar cohorts of patients.

Age, socioeconomic features, and clinical factors predict receipt of endoscopic retrograde cholangiopancreatography in pancreatic cancer.

BACKGROUNDEndoscopic retrograde cholangiopancreatography (ERCP) is the recommended technique for biliary decompression in pancreatic cancer. Previous studies have suggested racial, socioeconomic and geographic differences in diagnosis, treatment and outcomes of pancreatic cancer patients.AIMTo examine geographic, racial, socioeconomic and clinical factors associated with utilization of ERCP.METHODSSurveillance, Epidemiology and End Results and linked Medicare claims data were used to identify pancreatic cancer patients between 2000-2011. Claims data were used to identify patients who had ERCP and other treatments. The primary outcome was receipt of ERCP. Chi-squared analyses were used to compare demographic information. Trends in use of ERCP over time were assessed using Cochran Armitage test. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for receipt ERCP were calculated using logistic regression, controlling for other characteristics.RESULTSAmong 32510 pancreatic cancer patients, 14704 (45.2%) underwent ERCP. Patients who had cancer located in the head of the pancreas (aOR 3.27, 95%CI: 2.99-3.57), had jaundice (aOR 7.59, 95%CI: 7.06-8.17), cholangitis (aOR 4.22, 95%CI: 3.71-4.81) or pruritus (aOR 1.42, 95%CI: 1.22-1.66) and lived in lower education zip codes (aOR 1.14, 95%CI: 1.04-1.24) were more likely to receive ERCP. In contrast, patients who were older (aOR 0.88, 95%CI: 0.83, 0.94), not married (aOR 0.92, 95%CI: 0.86, 0.98), and lived in a non-metropolitan area (aOR 0.89, 95%CI: 0.82, 0.98) were less likely to receive ERCP. Compared to white patients, non-white/non-black patients (aOR 0.83, 95%CI: 0.70-0.97) were less likely to receive ERCP. Patients diagnosed later in the study period were less likely to receive ERCP (aOR 2004-2007 0.85, 95%CI: 0.78-0.92; aOR 2008-2011 0.76, 95%CI: 0.70-0.83). After stratifying by indications for ERCP including jaundice, racial differences persisted (aOR black patients 0.80, 95%CI: 0.67-0.95, nonwhite/nonblack patients 0.73, 95%CI: 0.58-0.91). Among patients with jaundice, those who underwent surgery were less likely to undergo ERCP (aOR 0.60, 95%CI: 0.52, 0.69).CONCLUSIONERCP utilization in pancreatic cancer varies based on patient age, marital status, and factors related to where the patient lives. Further studies are needed to guide appropriate biliary intervention for these patients.

Mirizzi syndrome management (in Russian only)

To assess an effectiveness of complex preoperative diagnosis, conservative treatment, minimally invasive biliary decompression for Mirizzi syndrome and to analyze surgical outcomes depending on the effectiveness of minimally invasive biliary decompression. There were 67 patients with Mirizzi syndrome aged 27-96 years (mean age -64.8 years). The diagnosis was established on the basis of complaints, objective data, laboratory survey, abdominal X-ray, ultrasound (US), endoscopic gastroduodenoscopy (EGDS), computed tomography (CT) and magnetic resonance imaging (MRI). Extrahepatic bile duct visualization in case of suspected biliodigestive fistula was achieved by using of percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, cholecystocholangiography, intraoperative cholangiography. The analysis of the diagnosis and treatment of patients with Mirizzi syndrome and mechanical jaundice with and without symptoms of cholangitis was carried out. It should be noted that percutaneous transhepatic cholangiography and cholecystocholangiography with antegrade contrasting were able to confirm Mirizzi syndrome type 1 without complications. Retrograde cholangiopancreatography in patients with Mirizzi syndrome type 2 reduced the diagnostic value of contrast-enhancement with complications in every fifth patient. Percutaneous drainage for Mirizzi syndrome type 1 was effective in all patients. There was low effectiveness of medication for Mirizzi syndrome. Medication combined with antegrade biliary decompression was 7 times more effective than retrograde decompression. All patients underwent surgery. Mortality depended on surgical emergency and effectiveness of biliary decompression. So, emergency interventions were followed by mortality rate near 60% while there were no deaths after elective procedures. Overall mortality was 11.9%.

Experience of treatment of acute cholangitis with the use of anti-bacterial photodynamic therapy

Introduction. Acute cholangitis is a life-threatening disease characterized by an ascending inflammatory and infectious process in the biliary tree. Biliary decompression and systemic or local antibiotic therapy are key points in the treatment of acute cholangitis, regardless of the etiology of the disease. At the same time, an evergrowing antibacterial resistance requires the search for new ones, including non-pharmacological methods of combating infectious agents, one of which is photodynamic therapy. The aim of the work is to assess the effectiveness of the use of antibacterial photodynamic therapy in the complex treatment of acute cholangitis. Materials and methods. The paper presents the experience of using antibacterial photodynamic therapy in the complex treatment of acute cholangitis in 7 patients with obstructive jaundice. Standard methods of percutaneous transhepatic cholangiosis and conservative treatment of acute cholangitis were supplemented by intraductal antibacterial photodynamic therapy according to the technique developed by the authors. Photolon (Belmedpreparaty, Republic of Belarus) was used as a photosensitizer. The radiation was supplied through a quartz-polymer fiber with a diameter of 400 μm. The radiation wavelength is λ = 660 nm, the radiation power is 50 mW. The exposure time is 5–7 minutes. Results. The bactericidal effect of antibacterial photodynamic therapy was established, expressed in a statistically significant decrease in microbial contamination in bile already on the 3rd day of the study with its complete eradication on the 6th day of the study (p < 0.05). The average treatment time for acute cholangitis was 11.2 ± 2.4 days. Findings. Thus, the use of bile duct drainage in combination with intraductal antibacterial photodynamic therapy allows to stop the cholangitis phenomenon, reduce the economic costs of treatment, as well as the subsequent rehabilitation of this category of patients.

Clinical Profile and Management Techniques of Surgical Obstructive Jaundice Cases in a Tertiary Center at Bareilly

Abstract Introduction Obstructive jaundice is associated with high morbidity and mortality. Obstructive jaundice is not a definitive diagnosis. Detailed evaluation to establish the etiology of the cholestasis and cause of obstruction is crucial to avoid secondary pathologic changes and to plan different surgical techniques to intervene at an early stage. Materials and Methods A cross-sectional study was conducted among 50 cases of surgical obstructive jaundice at Shri Ram Murti Smarak Institute of Medical Sciences (SRMSIMS), Bareilly. Results The mean age of this study population was 48.44 ± 8.2 years, and 48% (24) patients had obstructive jaundice of benign etiology, whereas 52% (26) had malignant etiology. Among males, the common presentation was choledocholithiasis in benign disease and carcinoma of the gallbladder among malignancy. In females also, disease presentation was similar to that of males. Percutaneous transhepatic biliary drainage (PTBD) was the most common method of biliary decompression in malignant group. For biliary decompression in patients of benign etiology, common bile duct (CBD) exploration with T-tube drainage was done in most cases. Conclusion Obstructive jaundice has different etiologic spectrum in both males and females. Irrespective of etiology, common presentation was pain (94% of the cases). Most patients with malignant etiology presented with palpable lump. PTBD was the most common method of biliary decompression in malignant group. CBD exploration with T-tube drainage has higher values of decrease in serum bilirubin, serum bilirubin (indirect), serum alkaline phosphatase, and albumin.

Outcomes and limitations: EUS-guided hepaticogastrostomy.

One of the major roles of interventional EUS is biliary decompression as an alternative to ERCP or percutaneous transhepatic biliary drainage. Among EUS-guided biliary drainage, EUS-guided hepaticogastrostomy with transmural stenting (EUS-HGS) may be the most promising procedure since this procedure can overcome the limitation of ERCP. However, EUS-HGS has disadvantages, and the safety issue is still not resolved. In this review, the clinical outcomes and limitations of EUS-HGS will be discussed.

COMPARATIVE ASSESSMENT OF BILE DUCT DECOMPRESSION METHODS IN PATIENTS WITH OBSTRUCTIVE JAUNDICE OF NON-TUMOR GENESIS

Introduction: Obstructive jaundice is one of the most common diseases of the digestive system observed in 10-15% of the world's population. The question of making a choice among methods of bile duct decompression is still under discussion, since both single-stage and two-stage methods of biliary decompression lead to progression of hepatic insufficiency after restoration of bile passage. The aim: To determine a tempo of biliary decompression after external and internal drainage of bile ducts, endoscopic transpapillary interventions in patients with obstructive jaundice of non-tumor genesis. Materials and methods: We analyzed the outcomes of surgical treatment of 180 patients with obstructive jaundice of the non-tumor genesis. The patients were divided into three groups: group I (n = 86), where endoscopic methods of biliary decompression were used; group II (n = 48), where biliodigestive anastomoses were formed; and group III (n = 46), where the external drainage of bile ducts was conducted. The average age was 62 ± 6.0 years. The average duration of obstructive jaundice was 20 ± 3.7 days. Results: The patients of the group I demonstrated a gradual decrease of bilirubin and alkaline phosphatase levels, which reached the normal readings on Day 7. The patients of the group II demonstrated normal levels of bilirubin and alkaline phosphatase on Day 14. The patients of the group III demonstrated rapid decrease of bilirubin and alkaline phosphatase levels, which reached the normal readings on Day 28. The transaminase level in each group of patients had reached the norm earlier. Conclusions: No significant disturbances of the functional state of the liver after endoscopic transpapillary interventions were observed. Formation of areflux biliodigestive anastomoses was accompanied by a moderate rate of biliary duct decompression. The external drainage of biliary ducts was characterized by a rapid rate of biliary decompression, leading to a post-compression syndrome.

Choledochoduodenostomy: Outcomes and limitations.

The EUS-guided biliary drainage (EUS-BD) has gained broad acceptance as the preferred approach after failed ERCP for malignant biliary obstruction. Despite the drainage route, namely, transhepatic or transduodenal, the technical and clinical success rates are high. Because of such good outcomes with tolerable adverse events (AEs) rate, the EUS-BD might soon even replace the ERCP for primary biliary decompression in patients at high risk of failed biliary cannulation. Among the EUS-BD techniques, the choledochoduodenostomy seems to carry the lower risk of AEs and should be considered the first-line EUS approach for biliary decompression.

Management of patients with malignant obstructive jaundice using bile examination after external biliary drainage

To determine optimal time of biliary tract decompression and bile reinfusion into gastrointestinal tract in patients with malignant obstructive jaundice. 179 medical records of patients with obstructive jaundice were analyzed in order to identify risk factors of postoperative complications. Prospective trial included bile examination in 34 patients with malignant obstructive jaundice. The new algorithm of preoperative preparation of patients was proposed using these data. Preoperative hyperbilirubinemia over 50 μmol/l before radical surgery and over 80 μmol/l before palliative surgery is followed by increase of postoperative morbidity from 42.1 to 66.7% and from 11.1 to 37.5%, respectively. The concentration of AST and ALT approaches the norm in 13.63±2.39 days after decompression. Five-day period after external drainage is characterized by the same level of overall bilirubin in the bile while bile reinfusion into gastrointestinal tract after 1-2 days leads to advanced symptoms of intoxication. The proposed tactics allows to reduce postoperative morbidity from 36.9 to 26.5% (p<0.05) and mortality from 5.5 to 2.9%, respectively (p<0.05). Duration of biliary decompression should be at least 13.63±2.39 days to reduce postoperative morbidity and mortality. Bile reinfusion into gastrointestinal tract should be started in 5-6 days after decompression.

Malignant obstructive jaundice: rational method of surgical treatment

Background: Aim of the study is to choose rational method of biliary decompression in patients with malignant obstruction. 260 patients had biliary decompression for the 6 year period Methods: We focused on the anatomical level of biliary tract occlusion. Obstruction at the level of the common bile duct(CBD) was detected in 78.8% cases , common hepatic duct(CHD) with untouched confluence in 8,3% , confluence and above on lobal and segmental level of occlusion in 12,9 % Results: Cholecystostomy (CS) was performed in 24.2% cases, Percutaneous biliary drainage (PBD) in - 13.2%, Endoscopic stenting (ES) in - 47.6%, In 14% of cases we had to combine the two different methods of draining jaundice because of the inefficiency one of them. ES was successful in 91.3% cases with an occlusion at the level of CBD, in 72.0% at the level of the CHD In cases with occlusion above confluence ES was not applied. PBD was successfully in 87.5% cases with obstruction at the level of the CBD, at the level of CHD - 90%, at the level of lobal and segmental hepatic ducts - 88.2%. CS was effective in 77.9%, in cases with obstruction below the mouth of the cystic duct.Complications occurred in 13% of cases. After ES leading complication was cholangitis. The main complications after PBD and CS was bile leakage into the peritoneal or pleural cavity. Conclusion: ES has priority in cases with an occlusion level of the CBD and CHD with untouched confluence, PHD in cases with occlusion level of lobal and segmental ducts.

Number of positive lymph nodes and lymphatic invasion are significant prognostic factors for distal cholangiocarcinoma

Introduction: Early recurrence of distal cholangiocarcinoma (DCC) may Result in a poorer prognosis. This study aimed to evaluate the clinicopathological factors that predict survival and recurrence in patients with DCC. Method: Fifty-five patients with DCC who underwent pancreaticoduodenectomy between 2005 and 2015 were studied retrospectively. The following clinicopathological parameters were analyzed as predictors of disease-free survival (DFS) and overall survival (OS): sex, age, body mass index, presence of biliary tract decompression, macroscopic type, histological type, tumor size, TNM classification, lymph node metastasis ratio, number of positive lymph nodes (PLN), lymphatic invasion, venous invasion, perineural invasion, proximal bile duct margin, dissected margin, portal system invasion, arterial system invasion, stage, and residual tumor. Result: Univariate analysis showed that contiguous extension of the primary tumor, PLN, lymphatic invasion, venous invasion, perineural invasion, and stage were significant prognostic factors for DFS and OS. Multivariate analysis revealed that PLN and lymphatic invasion were prognostic for DFS and OS (p<0.001). Significant differences in OS and DFS were found in analyses stratified by PLN (0, 1, 2 vs. ≥3) and lymphatic invasion (0 vs. 1, 2, 3). Conclusion: Among the clinicopathological parameters analyzed, PLN, and lymphatic invasion were confirmed as prognostic factors for DCC.

EUS-guided drainage: Summary of therapeutic EUS consortium meeting.

EUS-guided drainage is a safe and efficacious endoscopic technique for biliary, pancreatic, and gallbladder decompression. Recent literature has described many successful procedural techniques and devices to achieve EUS-guided drainage. This consortium gathering advanced endoscopists with expertise in both ultrasonography and therapeutic endoscopy, discuss the introduction to learning several EUS-guided drainage approaches, devices, and technology involved, possible obstacles to certain procedural and all potential complications.

Near-Infrared Cholangiography Can Facilitate a Laparoscopic Choledocholithotomy Even After Upper Abdominal Surgery

Introduction: Surgery for common bile duct (CBD) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. A minimally-invasive approach choledocholithotomy can be difficult and converted for the unclear biliary anatomy. Near-infrared (NIR) cholangiography by systemic administration of Indocyanine Green (ICG) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. NIR fluorescence cholecysto-cholangiography by direct biliary tree administration of the ICG can enhance the biliary tree without background noise signal. We created the NIR cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application Method: Ten patients who suffered from obstructive jaundice due to CBD stone and 5 patients received percutaneous biliary tree drainage as first treatment and 2 patients received endoscopic biliary tree drainage. Those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. 5 patients received biliary tree ICG injection via drain tube and 5 patients by systemic injection. Visualization and fluorescence patterns around CBD was recorded Result: In our series, one patient received previous gastrectomy and 4 patients had previous biliary tree surgery. 2 Patients received PTGBD and 3 patient received PTCD for biliary decompression. The near infra-red cholangiography of ten patients can show the clear margin of CBD. No intra or postoperative complications noted. Median time to CBD localization after ICG injection was 5.2 sec for biliary tree injection and 35 minutes for systemic injection. One patient converted to open method due to big stone impaction in distal CBD. No mortality and mobidity were found. Conclusion: Fluorescence cholangiography with ICG injection could provide visualization of CBD even inflammatory or post operative adhesion status, and direct injection method provide more real-time and noise-free image than systemic injection.

EUS-specific stents: Available designs and probable lacunae.

Interventional EUS has seen exponential growth in its indications and applications in the last decade.[1,2,3] Dedicated endoscopic devices for EUS-guided interventions are still limited. Up until recently, the tools used have been borrowed from other procedures such as ERCP. In interventional EUS, the linear-array echoendoscope allows a needle to be advanced under EUS-guidance from the upper gastrointestinal lumen to the biliary, pancreatic, or another adjacent intestinal lumen. Real-time puncture can be performed and provide the possibility of EUS-guided transluminal drainage (EUS-TLD). Plastic stents and conventional self-expandable metallic stents (SEMSs) were initially used but present several limitations due to their design.[1,4,5] They lack lumen-to-lumen anchorage and present migratory risks in the absence of stricture to hold them in place. Plastic stents are associated with potential pneumoperitoneum and bile peritonitis, whereas fully-covered SEMS (FCSEMS), despite preventing bile leak, will not maintain secure apposition between two nonadherent organs. Furthermore, their length often exceeds the anatomical requirement of a shorter transluminal anastomosis and predisposes them to obstruction as well as difficult positioning. With the rise in new EUS-guided interventional techniques, new tools, in particular, new stent designs have evolved to facilitate the various applications. A few EUS-specific stents have now become available for EUS-TLD.[4,5] We hereby review the stent designs and discuss lacunae to be addressed to improve the efficacy, safety, and ease of procedures.

Relief of Obstruction in the Management of Pancreatic Cancer

Pancreatic cancer is a major cause of cancer-related mortality and morbidity, and its incidence is increasing as the population is aging. On the other hand, significant improvement in the prognosis has not occurred. The absence of early diagnosis means that many patients are diagnosed only when they develop symptoms, such as jaundice, due to a biliary obstruction. The role of endoscopy in multidisciplinary care for patients with pancreatic cancer continues to evolve. Controversy remains regarding the best preoperative biliary drainage in patients with surgically resectable pancreatic head cancer. In general, patients undergoing a surgical resection usually do not require preoperative biliary drainage unless they have cholangitis or receive neoadjuvant chemotherapy. If biliary drainage is performed prior to surgery, the patient's condition and a multidisciplinary approach should be considered. With the increasing life expectancy of patients with pancreatic cancer, the need for more long-time biliary drainage or pre-operative biliary drainage is also increasing. Strong evidence of endoscopic retrograde cholangiopancreatography (ERCP) as a first-line and essential treatment for biliary decompression has been provided. On the other hand, the use of endoscopic ultrasound-guided biliary drainage as well as percutaneous biliary drainage has been also recommended. During ERCP, self-expandable metal stent could be recommended instead of a plastic stent for the purpose of long stent patency and minimizing stent-induced complications. In this review, several points of view regarding the relief of obstruction in patients with pancreatic cancer, and optimal techniques are being discussed.