Management of Hilar Biliary Strictures

Abstract

Biliary strictures at the liver hilum are caused by a heterogeneous group of benign and malignant conditions. In the absence of a clear-cut benign etiology, i.e. bile duct damage during surgery, hilar biliary strictures remain a diagnostic and therapeutic challenge for which a multidisciplinary approach is often necessary. A definitive diagnosis can be achieved in only 40-60% of the patients, while in all the other cases strictures are treated as though they are malignant until surgical pathology determines otherwise. Surgical resection is the only treatment that prolongs survival in patients with malignant strictures. Because these tumors frequently extend longitudinally via the hepatic ducts into the liver parenchyma, partial hepatic resection has been gradually added to biliary resection to ensure tumor-free surgical margins. For unresectable cases, endoscopic stenting of biliary obstruction is considered the preferred palliation modality to relieve pruritus, cholangitis, pain and jaundice, while the percutaneous approach has been reserved for cases of failure. Other modalities of treatment such as radiotherapy, chemotherapy, and photodynamic therapy currently remain investigational. For benign post surgical hilar strictures, surgical repair can be difficult and requires specific skills and experience. As an alternative, a multi-stent technique with endoscopic placement of an increasing number of stents over time until complete resolution of the stricture has been proposed.

Role of transforming growth factor-beta signaling pathway in pathogenesis of benign biliary stricture

“…Smad family proteins have been identified as signal transducers for the TGF-β superfamily. The expression of CTGF gene is regulated directly by TGF-β 1 . CTGF, which promotes cell proliferation and deposition of extracellular matrix (ECM), is a downstream medium in the process in which TGF-β 1 produces a marked effect on connective tissue cell.…”

“…They are usually iatrogenic, most frequently as a result of cholecystectomy [1] . The incidence of this complication has increased with the widespread use of laparoscopic cholecystectomy (LC) [2][3][4] .…”

Endoscopic “crossroads” in the management of malignant hilar strictures

“…Hilar cholangiocarcinomas are the most common type of primary extrahepatic bile duct cancers occurring at or near the junction of the right and left hepatic ducts or common hepatic duct. The modified Bismuth-Corlett system classifies such tumor into four types based on the extent of these lesions (types [1][2][3][4]. These can present with symptoms of biliary obstruction, and accurate diagnosis and staging are needed for further management.…”

“…The majority of hilar lesions are advanced and unresectable at the time of diagnosis, requiring palliative management. Palliative biliary drainage is effective in relieving obstructive symptoms, improving quality of life though there is no benefit on survival [2]. An endoscopic approach may be preferred to surgical or percutaneous methods and depends on the extent of the tumor and operability of the patient.…”

Comprehensive management of cholangiocarcinoma: Part II. Treatment

“…Nonetheless, potential disadvantages of PBD such as tumor seeding, injury of vasculature, perforation and increased difficulties during surgery (e.g., in bilioenteral anastomosis after natural downsizing of the bile duct following stent removal) should be also considered (Table 1). 12,[15][16][17] Endoscopic ultrasound-guided biliary drainage Occasionally, endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful and biliary drainage remains to be achieved by PTBD or surgery. A new approach with endoscopic ultrasound (EUS)-guided biliary drainage (EGBD) provides a potentially useful alternative.…”