MALIGNANT BILIARY

OBSTRUCTION: FROM
PALLIATION TO TREATMENT
BRIAN R BOULAY, DIVISION OF GASTROENTEROLOGY AND HEPATOLOGY,
DEPARTMENT OF MEDICINE, UNIVERSITY OF ILLINOIS HOSPITAL AND
HEALTH SCIENCES SYSTEM, CHICAGO, IL 60612, UNITED STATES
ALEKSANDR BIRG, DEPARTMENT OF MEDICINE, UNIVERSITY OF ILLINOIS
HOSPITAL AND HEALTH SCIENCES SYSTEM, CHICAGO, IL 60612, UNITED
STATES
INTRODUCTION

• Obstruction of the extrahepatic bile ducts from a malignant process presents both a diagnostic and
therapeutic challenge
• The two most common malignant neoplasms
• pancreatic ductal adenocarcinoma
• primary bile duct cancer (cholangiocarcinoma)
• Other causes : ampullary carcinoma, primary duodenal adenocarcinoma, Pancreatic neuroendocrine
tumors, or occlusion of the hepatic hilum due to lymphadenopathy at the porta hepatis
• both pancreatic cancer and cholangiocarcinoma are notorious for presenting at an advanced stage in
which immediate surgery is contraindicated
• Treatment :
• endoscopically placed single biliary prosthesis for pancreatic cancer
• hilar strictures can be more challenging to manage due to the need to access the left and right systems of the
biliary tree.
EFFECT OF JAUNDICE

• Impair cellular immunity, allowing tumor growth and metastasic progression

• Malabsorption of lipid soluble vitamins including vitamin K leading to coagulopathy
• Bacterial and endotoxin translocation allowing SIRS and sepsis
• Distal biliary obstruction  surgical
• Hilar obstruction  decompression
MALIGNANT DISTAL BILIARY
OBSTRUCTION

• Decompression via endoscopic stent placement can palliate jaundice and pruritus for symptomatic
relief
• Over the past decade the use of self-expanding metal stents (SEMS) has become more common for
treatment of both benign and malignant biliary strictures
• SEMS do not interfere with pancreaticoduodenectomy
RESECTABLE DISEASE

• Surgery  definitive treatment for early pancreatic cancer

• Preoperative biliary drainage (PBD) is not automatically recommended
• Van der Gaag et al (2010) demonstrating that PBD with stents increased complications compare to
surgery alone in resectable pancreatic cancer  PBD is not recommended except to treat cholangitis or
intractable pruritus
LOCALLY ADVANCED DISEASE AND NEOADJUVANT
THERAPY

• There is growing interest in the use of neoadjuvant therapy for boost outcomes
• Biliary stents are placed prior to neoadjuvant chemotherapy
• SEMS is preferable to plastic stents
• Anti-reflux stents have been developed to limit duodenal contents to bile duct and prevent stent
occlusion
• The use of removable plastic stents if benign conditions or diagnosis of malignancy is uncertain
NON-ENDOSCOPIC BILIARY DRAINAGE IN MALIGNANT
DISTAL OBSTRUCTION

• Percutaneous Trans-hepatic Biliary Drainage (PTBD)

• Endoscopic Ultrasound –Guided Biliary Drainage (EUS-BD)
• Surgical Biliary Bypass
HILAR CHOLANGIOCARCINOMA: SURGICALLY
TREATABLE DISEASE

• Difficult to treat
• May still require partial hepatic resection
• Contraindicated to surgery:
• Bismuth class 4 strictures
• Involvement of hepatic artery and portal vein
HILAR CHOLANGIOCARCINOMA: TECHNIQUES FOR
PREOPERATIVE BILIARY DRAINAGE

• PTBD
• Preferred method, low complication rates when compared to endoscopic stent placement
• Endoscopic Nasobiliary Drainage (ENBD)
• Safer technique than PTBD, discomfort for the patient
• Endoscopic Retrograde Biliary Drainage (ERBD)
• Technically challenging, high complication rate
HILAR CHOLANGIOCARCINOMA: PALLIATIVE THERAPY
FOR MALIGNANT BILIARY OBSTRUCTION

• PTBD is generally favored over endoscopic therapy

• The goal for palliative drainage is to relieve jaundice by draining 50% of liver volume
ENDOSCOPIC ADJUVANT TREATMENT OF BILIARY
OBSTRUCTION : MOVING BEYOND STENTING

• Photodynamic Therapy
• Radiofrequency Ablation
PHOTODYNAMIC THERAPY
CONCLUSION

• For most cases, preoperative biliary drainage is discouraged due to high incidence of infections
• In patients undergoing neoadjuvant for locally advanced disease, SEMS appears to be optimal approach
in distal strictures while for hilar strictures appears to favor PTBD or ENBD
• For palliation  PTBD
• Use of PDT and RFA is an important step to prolonging survival