Editorial
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 21, 2017; 23(7): 1119-1124
Published online Feb 21, 2017. doi: 10.3748/wjg.v23.i7.1119
Common controversies in management of biliary strictures
Mansour A Parsi
Mansour A Parsi, Center for Endoscopy and Pancreatobiliary Disorders, Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
Author contributions: Parsi MA solely designed, wrote and edited the manuscript.
Conflict-of-interest statement: No conflicts of interest related to this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mansour A Parsi, MD, MPH, Center for Endoscopy and Pancreatobiliary Disorders, Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States. parsim@ccf.org
Telephone: +1-216-4454880 Fax: +1-216-4446284
Received: September 14, 2016
Peer-review started: September 16, 2016
First decision: November 21, 2016
Revised: December 10, 2016
Accepted: January 18, 2017
Article in press: January 18, 2017
Published online: February 21, 2017
Abstract

Biliary strictures are caused by a heterogeneous group of benign and malignant conditions, each requiring a specific treatment approach. Management of biliary strictures often involves endoscopy either for definite treatment, as a bridge to surgery or for palliative purposes. Endoscopic treatment of various types of biliary strictures is not standardized and there are multiple areas of controversy regarding the best treatment options. These controversies are mainly due to lack of well-designed comparative studies to support a specific therapy. This paper reviews three common areas of controversy in the endoscopic management of biliary strictures. The areas discussed in this editorial include the role of biliary drainage in resectable malignant strictures and whether such drainage should be performed routinely prior to surgery, the best endoscopic palliation for unresectable hilar strictures and whether unilateral or bilateral stenting should be attempted, and the optimal endoscopic management for dominant strictures in patients with primary sclerosing cholangitis. The goal of this editorial is twofold. The first is to review the current literature on management of the aforementioned strictures and offer recommendations based on available evidence. The second goal is to highlight the gaps in our knowledge which in turn can encourage future research on these topics.

Keywords: Biliary stricture, Benign, Primary sclerosing cholangitis, Malignant, Controversy, Biliary drainage, Preoperative, Hilar stricture

Core tip: Based on available evidence preoperative biliary drainage is not routinely indicated in resectable malignant strictures. However, it is appropriate in acute cholangitis, in severely symptomatic patients and in those with delayed surgery. In patients with unresectable hilar stricture, cross-sectional imaging is advised prior to attempt at palliative drainage. In such patients unilateral stenting during endoscopic retrograde cholangiopancreatography is adequate in most cases. Routine stenting of dominant strictures in primary sclerosing cholangitis patients is not recommended. Stenting of dominant strictures is appropriate if there is poor drainage of contrast after dilatation or concern for collapse of the bile duct compromising biliary drainage.