<p>Early Diagnosis And Management Of Malignant Distal Biliary Obstruction: A Review On Current Recommendations And Guidelines</p>

Abstract

Malignant biliary obstruction is a challenging condition, requiring a multimodal approach for both diagnosis and treatment. Pancreatic adenocarcinoma and cholangiocarcinoma are the leading causes of malignant distal biliary obstruction. Early diagnosis is difficult to establish as biliary obstruction can be the first presentation of the underlying disease, which can already be at an advanced stage. Consequently, the majority of patients (70%) with malignant distal biliary obstruction are unresectable at the time of diagnosis. The association of clinical findings, laboratory tests, imaging, and endoscopic modalities may help in identifying the underlying cause. Novel endoscopic techniques such as cholangioscopy, intraductal ultrasonography, or confocal laser endomicroscopy have been developed with promising results, but are not used in routine clinical practice. As the number of patients with malignant distal biliary obstruction who will undergo curative surgery is limited, endoscopy has a crucial role in palliation, to relieve biliary obstruction. According to the last European guidelines published in the management of biliary obstruction, self-expandable metal stents have a central place in biliary drainage compared to plastic stents. Endoscopic ultrasound has evolved impressively in the last decades. When standard techniques of biliary cannulation by endoscopic retrograde cholangiopancreatography fail, endoscopic ultrasound-guided biliary drainage is a good option compared to percutaneous drainage.

Bile-Based Cell-Free DNA Analysis Is a Reliable Diagnostic Tool in Pancreatobiliary Cancer

“…In addition, we do not provide a systematic comparison between different approaches to the diagnosis of pancreatobiliary malignancies. About 70% of patients with pancreatic cancer present with inoperable malignant biliary strictures requiring biliary drainage in order to improve quality of life and to allow for palliative chemotherapy treatment [36,37]. However, not all patients with pancreatobiliary cancers require therapeutic interventions for biliary drainage.…”

Optimization of biliary drainage in inoperable distal malignant strictures

“…Given the results of our study, we supposed that HCMS stents are the best choice in this group of patients due to the inherent advantages of both types of its characteristics. However, early occlusions of the HCMS and FCMS were noticed due to tumor overgrowth, and these finding were surprising and controversial, when compared with other studies[ 15 , 20 , 23 , 30 - 34 ]. Conio et al[ 20 ] have explained that this overgrowth may be due to a created tissue hyperplasia induced by inflammatory reaction caused by the membrane covering of the stents rather than a true tumor overgrowth.…”

“…Probably in these trials, the endoscopists used stents with an anti-migration system consisting of a portion of uncovered flares at both ends[ 24 ]. However, Yang et al[ 15 ] found no clinical usefulness of the anti-migration design[ 15 , 34 ].…”

Endoscopic Management of Malignant Biliary Stricture

“…However, surgical bypass does seem to be superior in avoiding recurrent jaundice. The decision to perform endoscopic stent placement versus surgical bypass should be considered carefully, with the risks and benefits of each procedure discussed thoroughly with patients [9,10].…”