Page 49 - Read Online

Page 12 of 16 Chandrasekar et al. Mini-invasive Surg 2021;5:33 https://dx.doi.org/10.20517/2574-1225.2021.12

Figure 5. Treatment algorithm for management of malignant biliary obstruction. MBO: Malignant biliary obstruction; SEMS: self-
expanding metal stents; FCSEMS: fully covered self-expanding metal stents; USEMS: uncovered self-expanding metal stents; ERCP:
endoscopic retrograde cholangiopancreatography; EUS: endoscopic ultrasound; BD: biliary drainage; PTBD: percutaneous transhepatic
biliary drainage; HGS: hepaticogastrostomy.

CONCLUSION
A diagnosis of biliary malignancy should be pursued in patients demonstrating features of biliary
obstruction and elevated liver enzymes in the appropriate clinical setting. The diagnostic algorithm involves
obtaining tumor markers and imaging for evaluation of the biliary tract prior to tissue sampling with
endoscopic techniques - EUS or ERCP. ERCP-guided brushings and forceps biopsies are the most common
modality for diagnosis, but cholangioscopy guided direct biopsies can be obtained for indeterminate biliary
strictures with prior inconclusive ERCPs. Treatment is mainly aimed at biliary drainage with trans-papillary
stenting in unresectable cancers as a palliative measure, with metal stents generally preferred for distal
cancers and plastic stents for more proximal tumors. For resectable cancers, up-front surgery is generally
preferred unless it is delayed for neo-adjuvant chemotherapy or in patients with cholangitis, in which case
ERCP with stenting should be performed [Figure 5]. Among SEMS, there are no data to demonstrate the
superiority of one type over the other and hence decisions should be individualized to the patient. Recent
advances in interventional EUS can help with both diagnoses and for biliary drainage in patients with failed
ERCP or with inaccessible papilla. Despite the significant progress in this field, there are still some
deficiencies that need to be addressed and further research with RCTs is needed.

DECLARATIONS
Authors’ contributions
Conception and design, data acquisition, drafting of manuscript, revision of manuscript: Thoguluva
Chandrasekar V
Conception and design, critical review, revision of manuscript: Faigel D