विवरण
The management of malignant biliary strictures involves a multidisciplinary approach aimed at relieving obstruction, improving quality of life, and potentially extending survival. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is a common intervention to alleviate biliary obstruction. Metal stents are preferred over plastic stents for their durability and longer patency. In cases where ERCP is not feasible, percutaneous transhepatic biliary drainage may be employed. Systemic chemotherapy or radiation therapy may be considered as part of a comprehensive treatment plan, particularly in cases where the malignancy is unresectable. Surgical resection remains the curative option when feasible. Palliative care plays a crucial role in managing symptoms and enhancing the overall quality of life for patients with advanced disease. Close collaboration among gastroenterologists, oncologists, interventional radiologists, and surgeons is essential for the optimal management of malignant biliary strictures.
सारांश
- Indeterminate biliary strictures pose a significant diagnostic challenge, with a high likelihood of malignancy. Initial ERCP with brush cytology and biopsy can often be inconclusive, necessitating further investigation. While repeating ERCP with brushing and biopsy, including FISH analysis, is an option, EUS with FNA, ERCP with cholangioscopy and biopsy, or even surgery, are also considered.
- The diagnosis of biliary strictures involves assessing whether the stricture is benign or malignant and addressing the dilemma of indeterminate strictures. Cholangiocarcinoma, classified into intrahepatic, hilar, and distal types, contributes significantly to primary liver and GI cancers. Hilar cholangiocarcinoma is further subdivided using the Bismuth classification.
- Endoscopic diagnostic methods include brush cytology, fluoroscopy-guided biopsies, FISH, cholangioscopy, confocal imaging, and EUS-FNA. Brush cytology is a first-line approach, while cholangioscopy offers targeted biopsies and enhanced visualization. Artificial intelligence and next-generation sequencing are emerging technologies that may improve diagnostic accuracy.
- EUS with FNA is a valuable tool for evaluating biliary strictures, offering better biopsy results compared to brush cytology. EUS can also avoid ERCP and assess lymph nodes. However, FNA of hilar structures carries a risk of seeding and may impact transplantation eligibility.
- The ASGE guidelines recommend metallic stents for unresectable malignant high biliary obstructions due to their higher patency and lower rate of re-intervention. Plastic stents may be considered if optimal drainage is uncertain. Double stenting is preferred over single stenting in unresectable cases, offering improved survival and patency.
- Key principles in managing high biliary strictures include thorough review of imaging, multidisciplinary team discussion, and avoiding over-injection of contrast. The goal of drainage is to achieve more than 50% of the viable liver volume. Wire, dilate, and stent is a useful reminder for proper stenting technique.
नमूना प्रमाण पत्र
वक्ताओं के बारे में
डॉ. खालिद बामखरामा
कंसल्टेंट फिजिशियन और गैस्ट्रोएंटेरोलॉजिस्ट, रशीद अस्पताल, डीएक्सबी
वित्तीय प्रकटीकरण
टिप्पणियाँ
टिप्पणियाँ
टिप्पणी करने के लिए आपको लॉगिन होना होगा।