Palliation: Hilar cholangiocarcinoma

Abstract

Hilar cholangiocarcinomas are common tumors of the bile duct that are often unresectable at presentation. Palliation, therefore, remains the goal in the majority of these patients. Palliative treatment is particularly indicated in the presence of cholangitis and pruritus but is often also offered for high-grade jaundice and abdominal pain. Endoscopic drainage by placing stents at endoscopic retrograde cholangio-pancreatography (ERCP) is usually the preferred modality of palliation. However, for advanced disease, percutaneous stenting has been shown to be superior to endoscopic stenting. Endosonography-guided biliary drainage is emerging as an alternative technique, particularly when ERCP is not possible or fails. Metal stents are usually preferred over plastic stents, both for ERCP and for percutaneous biliary drainage. There is no consensus as to whether it is necessary to place multiple stents within advanced hilar blocks or whether unilateral stenting would suffice. However, recent data have suggested that, contrary to previous belief, it is useful to drain more than 50% of the liver volume for favorable long-term results. In the presence of cholangitis, it is beneficial to drain all of the obstructed biliary segments. Surgical bypass plays a limited role in palliation and is offered primarily as a segment III bypass if, during a laparotomy for resection, the tumor is found to be unresectable. Photodynamic therapy and, more recently, radiofrequency ablation have been used as adjuvant therapies to improve the results of biliary stenting. The exact technique to be used for palliation is guided by the extent of the biliary involvement (Bismuth class) and the availability of local expertise.

Keywords: Cholangiocarcinoma, Hilar cholangiocarcinoma, Klatskin’s tumor, Palliation, Biliary stenting

Core tip: The majority of patients with hilar cholangiocarcinoma present in advanced stages and are candidates for palliation only. The techniques of palliation, primarily at endoscopy or by percutaneous techniques, are evolving as better stents become available. Alternate techniques, such as endosonography-guided procedures, are also becoming popular. Photodynamic therapy and radio-frequency ablation are also used to improve the results of biliary stents. This review article provides a consolidated picture of the present knowledge in this field based on recent data.