Published online Jun 15, 2016. doi: 10.4251/wjgo.v8.i6.498
Peer-review started: July 19, 2015
First decision: September 17, 2015
Revised: March 14, 2016
Accepted: April 21, 2016
Article in press: April 23, 2016
Published online: June 15, 2016
Malignant obstruction of the bile duct from cholangiocarcinoma, pancreatic adenocarcinoma, or other tumors is a common problem which may cause debilitating symptoms and increase the risk of subsequent surgery. The optimal treatment - including the decision whether to treat prior to resection - depends on the type of malignancy, as well as the stage of disease. Preoperative biliary drainage is generally discouraged due to the risk of infectious complications, though some situations may benefit. Patients who require neoadjuvant therapy will require decompression for the prolonged period until attempted surgical cure. For pancreatic cancer patients, self-expanding metallic stents are superior to plastic stents for achieving lasting decompression without stent occlusion. For cholangiocarcinoma patients, treatment with percutaneous methods or nasobiliary drainage may be superior to endoscopic stent placement, with less risk of infectious complications or failure. For patients of either malignancy who have advanced disease with palliative goals only, the choice of stent for endoscopic decompression depends on estimated survival, with plastic stents favored for survival of < 4 mo. New endoscopic techniques may actually extend stent patency and patient survival for these patients by achieving local control of the obstructing tumor. Both photodynamic therapy and radiofrequency ablation may play a role in extending survival of patients with malignant biliary obstruction.
Core tip: Treatment of malignant biliary obstruction from cholangiocarcinoma or pancreatic cancer can be performed via endoscopic, percutaneous, or surgical means. The decision of when or how to achieve biliary decompression depends on the patient’s condition, location of stricture, and stage of malignancy. Not all patients require biliary decompression, particularly with resectable tumors. Self-expanding metallic stents or plastic stents may be used for distal malignancy, depending on stage and prognosis. Stents, nasobiliary drainage, or percutaneous drains may be used for hilar strictures. Endoscopic catheter-based therapies such as photodynamic therapy or radiofrequency ablation may prolong patient survival by achieving local tumor control.