| Malignant hilar biliary stenosis caused by various etiologies, external compression from gallbladder cancer, metastasis tumor and also bile duct cancer itself. North-East part of Thailand is the most incidence of cholangiocarcinoma in the world due to chronic infection and inflammation from liver fluke, Opitorchis viverrini (Sripa B, Pairojkul C. Current opinion in gastroenterology. 2008;24:349-356.) Worldwide, resectable rate for hilar biliary stenosis is less than 25% (Lee SG, et al. J Hepatobiliary Pancreat Sci. 2010;17:476-489) because of late diagnosis with extensive invasion of complex surrounding important anatomy. Most of this patient with jaundice, palliative biliary drainage should be considered. Either trans-papillary or trans-hepatic drainage will be selected depending the extension of stenosis, namely Bismuth-Corlette classification, and degree of stenosis. For Bismuth-Corlette III and IV, the outcomes of percutaneous stenting are superior to endoscopic stenting in term of higher success rate and lower cholangitis rate from Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma (Rerknimitr R, et al. Journal of Gastroenterology and Hepatology.2013;28:593-607) and Metallic stent found better plastic stent in term of stent patency and survival. (Sangchan A, et al. Gastrointest Endosc. 2012;76:93-9, Rerknimitr R, et al. Journal of Gastroenterology and Hepatology.2013;28:593-607). Consideration of endoscopic biliary drainage, the current evidence showed not only metallic stent placement but also at least 50% of volume of drainaged liver segment are important as well (Vienne A, et al. Gastrointest. Endosc. 2010; 72: 728-35.). However, cholangiocarcinoma has relatively slow progression tumor. In case of previous metal stent placement, recurrent jaundice from tumor progression will be challenging situation to place more metal stent. The new evidence showed simultaneous or subsequent combined trans-papillary and transmural drainage by endoscopic guidance is promising giving maximum yield of biliary drainage (Kongkam P, et al. ESGE Day2018, April 20, 2018). |
