Abstract
Treatment of malignant biliary obstruction (MBO) requires the coordination of multiple
specialties, including oncologists, surgeons, gastroenterologists, and interventional
radiologists. If the tumor is resectable, surgical candidates can usually proceed
to surgery without preoperative biliary drainage. For patients who undergo biliary
drainage, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic
cholangiography (PTC) combined with biliary stenting are techniques with comparable
technical success and mortality, each with distinct advantages and risks. Advances
in endoscopic ultrasound allow drainage in patients with challenging anatomy. There
are a multitude of devices used for biliary decompression. Self-expanding metal stents
(SEMS), with longer patency rates, are in most instances preferred over plastic stents
for MBO, especially in patients with life expectancy more than 3 to 4 months. Advantages
of covered SEMS versus uncovered SEMS remain controversial as covered stents can prevent
tumor ingrowth but at the expense of potential increase in stent migrations. Extra-anatomic
biliary drainage using lumen-apposing metal stents is an emerging technique which
shows promise when conventional ERCP fails. It is imperative to understand these techniques
when tailoring a treatment strategy. The goal of this article is to discuss a multidisciplinary
approach for MBO to promote comprehensive care using case examples to highlight essential
principles.
Keywords
malignant biliary obstruction - percutaneous transhepatic cholangiography - endoscopic
retrograde cholangiopancreaography - biliary stents
