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Hilar Malignant Strictures

  • Anand Singla
  • Richard A. Kozarek
Chapter

Abstract

When it comes to endoscopic management, a malignant stricture at the biliary confluence poses a significant challenge to the therapeutic endoscopist both diagnostically and therapeutically. The diagnostic goal is to determine malignant or benign etiology of a biliary stricture and to determine resectability. In addition to proper imaging of the biliary hilum with computed tomography (CT) and magnetic resonance (MR), endoscopic tissue acquisition is an extremely important component to determining the etiology of a biliary stricture, specifically to differentiate between malignant and benign process. Brushings for cytology, intraductal biopsies, and even endoluminal fine-needle aspiration can all be performed at the time of endoscopic retrograde cholangiography (ERC), while endoscopic ultrasound (EUS) offers additional opportunity for fine-needle aspiration. Peroral cholangioscopy is an emerging technique that can directly visualize a malignant hilar stricture and allow for directed biopsies. Therapeutically, the ultimate goal is palliative biliary drainage to relieve biliary obstruction. This can be accomplished endoscopically with the placement of plastic or metal biliary stents to drain the most obstructed lobe of the liver, with uncovered self-expanding metal stents (SEMS) being preferred. Photodynamic therapy and radiofrequency ablation are emerging endoscopic techniques that allow for localized destruction of tumor cells, potentially improving biliary drainage, quality of life, and survival in most patients, but require further randomized, controlled studies.

Keywords

Malignant hilar stricture Biliary stricture Cholangiocarcinoma Endoscopic retrograde cholangiography (ERC) Cholangioscopy Biliary stent Photodynamic therapy 

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Copyright information

© Springer Japan KK, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of GastroenterologyUniversity of WashingtonSeattleUSA
  2. 2.Digestive Disease InstituteVirginia Mason Medical CenterSeattleUSA

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