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Page 8 of 16 Chandrasekar et al. Mini-invasive Surg 2021;5:33 https://dx.doi.org/10.20517/2574-1225.2021.12

Figure 3. Spyglass cholangioscopy demonstrating infiltrative mass in the bile duct with abnormal vasculature and friable mucosa in a
patient with cholangiocarcinoma.

who underwent pre-operative drainage, but also demonstrated an increase in complications post-
operatively for these patients [58,59] . Specifically, cholangitis is a clinical concern as placement of a stent for
biliary drainage would increase the risk of infection in an otherwise sterile field without an ERCP. Another
RCT comparing endoscopic and percutaneous transhepatic biliary drainage (PTBD) for pre-operative
biliary drainage was terminated early due to higher mortality in the PTBD arm (41%) compared to
endoscopic drainage (11%) . A meta-analysis by Fang et al. also demonstrated no mortality benefit for
[61]
[60]
pre-operative biliary drainage. For distal strictures due to pancreatic cancer and asymptomatic
hyperbilirubinemia, the American Society for Gastrointestinal Endoscopy recommends against routine
preoperative biliary drainage. Endoscopic biliary drainage pre-operatively should be reserved for patients
who have cholangitis, significant symptoms due to obstruction like pruritis and for those patients
undergoing neo-adjuvant chemotherapy in order to bring the higher bilirubin levels down prior to
[62]
chemotherapy . It is also ideal to delay the surgery a few weeks after biliary drainage if able, for the hepatic
function to normalize, to improve the post-operative outcomes. For distal cancers, pancreatico-
duodenectomy or Whipple’s procedure is the treatment of choice. For intra-hepatic tumors, resection of the
tumor with negative margins with or without portal lymphadenectomy is generally performed. For peri-
hilar tumors, hepatic lobectomy or trisectionectomy along with resection of the extra-hepatic bile duct and
gall bladder with a Roux-en-Y hepatico-jejunostomy is performed.

Unresectable cancers
Most CCA, close to 70%-80%, are unresectable at the time of diagnosis and endoscopic procedures in these
patients are mainly palliative to decompress the biliary tract and improve quality of life but have no
mortality benefit. The endoscopic options available are ERCP with biliary stenting which is the primary
palliative modality, EUS guided biliary drainage, endoscopic radiofrequency ablation or photodynamic
therapy (PDT). Percutaneous biliary drainage (PTBD) is also an approach used for palliation. It is generally
used for segmental biliary obstruction due to tumors in the intra-hepatic bile ducts where endoscopic
therapy may not be feasible or in selected patients with hilar CCAs. A study by Lee et al. evaluated
[63]
outcomes for PTBD and endoscopic drainage for various types of Bismuth classification lesion. For type I
and II lesions, there was no difference in the stent patency rates between both the groups for metal stent
placement using either method. The best results were seen with endoscopic drainage in Bismuth type III
lesions and PTBD for Bismuth type IV lesions . Several studies have been performed comparing these two
[63]
techniques of biliary drainage, including meta-analyses and results have shown that both techniques are