| Invited Lecture (JGES) |
| Fri. November 2nd 11:20 - 12:00 Room 5: Portopia Hotel South Wing Ohwada A |
| The current state and problem of endoscopic treatments for the malignant biliary stenosis | |||
| Thierry Ponchon | |||
| Digestive Disease Department, Edouard Herriot Hospital | |||
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| Endoscopic treatment for the malignant biliary stenosis consists of 1) biliary drainage 2) stenosis ablation. A first pre-requisite is to determine the nature of the stenosis (malignant versus benign) and a second pre-requisite is to perform a complete analysis of the lesion (CT, MRI, EUS, …) and an evaluation of the patient to assess the resectability of the tumor and the operatibility of the patient. A multidisciplinary decision is recommended prior any endoscopic approach of the bile duct, except in case of severe cholangitis. In case the lesion is not resectable or in case the patient is not operable, ERCP can be attempted as an alternative to percutaneous approach. Percutaneous approach can be recommended in case of very complex hilar stenosis or if there is still a doubt concerning a sclerosing cholangitis. Biliary drainage: MRCP is mandatory to analyze the level of biliary invasion, such as a CT to evaluate the respective volumes of the hepatic lobes and the potential invasion of the portal veins. In case of common bile duct stenosis, ERCP is the gold standard for the drainage. The discussion is in between covered and uncovered metal stent (covered stent has longer patency but can induce cholangitis). In case of hilar stenosis, the discussion is in between complete or incomplete drainage. Multiple stenting (2 to 3 stents) is recommended if possible. Drainage has been recently optimized thanks to the usage of orientable catheters, J-shape hydrophilic guide-wires and uncovered long metal stents (side to side or stent-in-stent). Recent advances consist in EUS guided drainage of the bile ducts (hepaticogastrostomy to drain the segment III of the left lobe or choledochoduodenostomy). The debate is in between ERCP first or EUS drainage first. More data are needed: ERCP first is still the technique of choice. Tumor ablation: Different techniques for intra-biliary tumor ablation have been published in the past, such as brachytherapy, photodynamic therapy, microwaves. Photodynamic therapy has been demonstrated effective but has been almost abandoned because of the side-effects (cutaneous photo-toxicity) and because of the cost. The last advance consists to use radiofrequency: the technique is simple and cheap. Recent publications have demonstrated a tumoral response and an improvement of the biliary drainage but also an interesting effect on the survival. |
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