Current Status of Endoscopic Treatment of Advanced Hilar Cholangiocarcinoma

Abstract

Cholangiocarcinoma is a high-mortality primary hepatic malignancy. A higher incidence of cholangiocarcinoma was reported in Asia, especially Southeast Asia, than in Western countries. Hilar cholangiocarcinoma is a specific type of extrahepatic cholangiocarcinoma that involves the hepatic hilum and has a worse prognosis. More than half of the patients with jaundice are inoperable at the time of first diagnosis. Therefore, biliary drainage is the mainstay of palliative treatment in these patients. Endoscopic biliary drainage via endoscopic retrograde cholangiopancreatography, the modality of choice, for the advanced hilar type is more difficult and complex than those in distal cholangiocarcinoma. Endoscopists should consider many factors before selecting the most appropriate treatment for each patient. Here we discuss the factors systematically. In cases of transpapillary approach failure, other therapeutic modalities should be considered. Percutaneous transhepatic biliary drainage is the most popular method in such cases. At the present, endoscopic ultrasound-guided biliary drainage, especially hepaticogastrostomy, is an alternative procedure with the same efficacy and low complications when it was carried out in the expert hands. Furthermore, recent locoregional therapies for tumor control including trans-luminal photodynamic therapy and radiofrequency ablation also benefit these patients.

Extrahepatic cholangiocarcinoma: Current status of endoscopic approach and additional therapies

“…Acute cholangitis, sepsis, bilirubin > 10-15 mg/dL, scheduled neoadjuvant therapy and the need for extensive hepatic resection are indications for preoperative biliary drainage. The goal is to reduce peri- and postoperative complications[ 23 , 24 , 26 , 29 ]. Cholestasis, liver dysfunction and biliary cirrhosis can develop rapidly with unrelieved obstruction and may influence postoperative morbidity and mortality after surgery[ 23 - 26 , 33 ].…”

“…PTBD is no longer recommended for preoperative biliary drainage in patients with extrahepatic CCA, and an endoscopic approach is currently preferred[ 24 , 26 ]. The risk of endoscopic plastic stent occlusion is 60%.…”

“…In patients with pCCA and dCCA who are not suitable for surgery or liver transplantation, the guidelines recommend endoscopic bile duct drainage as the first approach[ 23 , 24 , 26 , 34 ]. In patients with a good performance status an additional treatment, such as chemotherapy, radiotherapy, molecularly targeted therapy and/or immunotherapy, is recommended[ 25 ].…”

“…Each subtype of CCA has different clinical management[ 24 ]. Therefore, an individualized approach is mandatory for pCCA or dCCA.…”

“…Stenting may relieve the jaundice and pruritus and improve the quality of life[ 26 ]. In ERCP, a unilateral or bilateral plastic or metallic stent can be used[ 23 , 24 , 26 ].…”