Guidance on drainage
For management, the principal objective is to restore the physiologic flow of bile into the duodenum. Although there is wide variability in the difficulty and risk of drainage, depending on location and complexity, perihilar strictures are generally more challenging and are riskier to drain than extrahepatic strictures. The goals should be to alleviate symptoms, reduce serum bilirubin to a level such that chemotherapy can be safely administered, and optimize surgical outcomes.
For benign extrahepatic biliary strictures, ERCP is the preferred modality for durable treatment. Fully covered self-expanding metallic stent (SEMS) placement is recommended over multiple plastic stents to reduce the number of procedures required for long-term treatment.
For extrahepatic strictures due to resectable pancreatic cancer or cholangiocarcinoma, the authors recommend against routine preoperative biliary drainage. However, drainage is warranted for some patients, including those with acute cholangitis, severe pruritus, very high serum bilirubin levels, those undergoing neoadjuvant therapy, and those for whom surgery is delayed.
For malignant extrahepatic strictures that are unresectable or borderline resectable, SEMS placement is recommended over plastic stents. The evidence is insufficient to recommend for or against uncovered SEMS versus fully covered SEMS.
For perihilar strictures due to suspected malignancy, the evidence is insufficient to recommend for or against ERCP versus percutaneous transhepatic biliary drainage. In addition, for malignant perihilar strictures, the evidence is insufficient to recommend for or against plastic stents versus uncovered SEMS.
For perihilar strictures due to cholangiocarcinoma in cases in which resection or transplantation is not possible, adjuvant endobiliary ablation plus plastic stent placement is recommended over plastic stent placement alone.
Overall, for patients with a biliary stricture for which ERCP is indicated but is unsuccessful or impossible, EUS-guided biliary access and drainage is recommended over PTBD, because it is associated with fewer adverse events. However, these interventional EUS procedures should be performed by an endoscopist with substantial experience.
“The workup of biliary strictures is challenging, invasive, and costly, requiring multiple diagnostic tools with highly variable yields,” co-author Victoria Gomez, MD, associate professor of medicine and director of bariatric endoscopy at Mayo Clinic, Jacksonville, Fla., said in an interview.
“Providers caring for these patients must be up to date with the most current evidence so that they can make the safest and most well-informed decisions for their patients,” she said. “These include considerations such as limiting the use of anesthesia, using tests that will result in the highest diagnostic yield, and providing effective therapies to decompress biliary obstruction.”
Future questions
Additional research is needed in several areas to strengthen recommendations and advance the field, the study authors write.
“Biliary strictures without an associated mass are a diagnostic challenge, and there are exciting opportunities to understand how new technologies, such as artificial intelligence, can be used to improve our assessment,” co-author Anna Tavakkoli, MD, assistant professor of internal medicine in digestive and liver diseases at the University of Texas Southwestern Medical Center, Dallas, said in an interview.
“Also, we highlighted several controversies in the drainage of perihilar strictures, including whether to use ERCP versus percutaneous drainage, whether metallic or plastic stents are better, and what the optimal stent placement should be,” she said. “Future multicenter studies are needed to address these key controversies.”
Although fully covered SEMS placement remains effective for benign biliary strictures, multiple plastic stents may be a better alternative in some cases. Such cases include those in which the stricture is close to the hilum, those in which the gallbladder is intact and in which crossing the cystic duct orifice cannot be avoided, those in which a fully covered SEMS has previously migrated or was not well tolerated, and those in which stricture has recurred after removal of a fully covered SEMS.