Endoscopic management of perihilar cholangiocarcinoma

Abstract

Endoscopic management for perihilar cholangiocarcinoma (PHCC) is evolving toward more accurate diagnosis and safer drainage. In imaging, it is important to diagnose the entire lesion using multidetector‐row computed tomography to determine resectability and optimal surgical planning, followed by local diagnosis using endoscopic retrograde cholangiopancreatography. Video peroral cholangioscopy and probe‐based confocal laser endomicroscopy have been newly introduced as diagnostic imaging methods and are being applied clinically. In transpapillary forceps biopsy for PHCC diagnosis, the location in the bile duct (for mapping biopsy) and the number of biopsy samples should be determined depending on resectability, the morphological type, and future surgical planning. Preoperative drainage has shifted from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage given the possibility of seeding metastasis. In addition, considering potential patient discomfort from a nasal tube, the usefulness of the placement of a plastic stent above the papilla (inside stent) as a bridging therapy for surgery has been reported. For drainage of unresectable PHCC, the improved prognosis due to advances in chemotherapy has necessitated a strategy that accounts for reintervention. Thus, in addition to uncovered self‐expandable metallic stents (SEMS), exchangeable slim fully covered SEMS and inside stents have started to be used. In addition to the conventional transpapillary approach, an endoscopic ultrasonography‐guided approach has been introduced, and a combination of both methods has also been proposed. To improve the quality of life and prognosis of PHCC patients, endoscopists need to understand and be able to use the various methods of endoscopic management for PHCC.

Bile liquid biopsy is a useful modality for molecular diagnosis of cancerous tumors in pancreatic head lesions

“…Thus, genomic information from bile cfDNA accurately re ects tissue-derived genomic pro les. Generally, the accuracy of pathologic diagnosis of BTC by endoscopic biopsy is relatively low (40-65%) [31,32] and we often face the di culty of accurate diagnosis by biopsied samples in cases with apparent bile duct stenosis. Regarding ampullary carcinoma, endoscopic biopsy for pathological diagnosis is di cult in cases with non-exposed tumor type [33].…”

Retrospective comparative study of new slim‐delivery and conventional large‐cell stents for stent‐in‐stent methods for hilar malignant biliary obstruction

“…As mentioned above, technical success rates of reinterventions were 100% but >10% of patients eventually had PTBD placed due to uncontrolled cholangitis by an endoscopic approach alone. EUS-BD has been increasingly reported in HMBO; [32][33][34][35] EUS-BD was also performed in 9% but its rate was still lower than PTBD. Access to the left biliary system is more feasible in EUS-BD, a combination of transpapillary stenting in the right biliary system and EUS-BD in the left biliary system can be a treatment option for high-grade HMBO to avoid PTBD as reinterventions.…”

Securing threads with a novel clip to prevent preceding stent migration in multiple biliary inside plastic stents

“…Endoscopic bilateral biliary plastic stent placement above the papilla (“inside stent”) is favored for drainage in patients with unresectable malignant hilar obstruction, as it offers longer stent patency and easy removability 1,2 . However, proximal dislocation of the first stent during second stent insertion can occur owing to interference between the stents.…”