Thank you. First of all, thanks to the organization for inviting me and giving me the challenge to tell you about this topic in 10 minutes. Okay, I'm going to give it a try. Let's see if this is going to work. It should be. These are my disclosures. And as I have only limited time, I thought to start with the end in mind. So what I hope you get from this presentation is the following. Before biliary stenting gets the diagnostics fixed, know where the location is, where the structure is, and really be aware of the indication. And if you consider stenting basically for extra hepatic, fully covered or uncovered self-expandable metal stent, and for the intra-hepatics, I really like the new guidelines, which is stating start with plastics. So this is all, but now I'm going to tell a bit more what's behind. So if you're ready to get for biliary stenting, I think first of all, you have to differentiate between malignant and benign disease. And here you see a nice overview. Basically, it will be malignant what we're going to treat, but there might also be benign cases, as should be. It's a bit cumbersome to click to the next one. Yeah, there it is. You can also have benign origin of the structure, for example, chronic pancreatitis. So to make the difference if it's benign or is it malignant, of course, you can do lots of diagnostic, lots of imaging. But I think in the end, it comes down to tissue is the issue. And you can either do that with a brush or you can do that with a puncture. Personally, I really like to get tissue. So to try to do it with EOS guided and get proper tissue. So if you have the diagnosis benign or malignant, then you can continue to the next step. And that's location. And the location is particularly important if you're going to stent afterwards. What's the relation to the hilum? Can I use plastic? Should I use metal? So do proper imaging. And personally, I like to start with a CT scan if you think it's a pancreatic heart sinoma. But if you think it might be a hilar lesion, then also an MRCT can be very, very helpful. So the second thing before you do stenting is to know your location. And as said, in particular for the hilar, if you are going to do hilar stenting, be very well prepared. You really need a roadmap. Which side of the liver are you going to drain? For what reason? What's going to stay behind? And you need there a multidisciplinary meeting. Don't think you can just judge that on your own. You need to know what the surgeon's plan is. What can you do yourself? And if you just go in unprepared, you really might do harm to your patients. So for the hilar structures, be additionally prepared. So and then with regards to the indication, I think you should not just stent. There should really be a reason behind. And that might be either a bilirubin level that's really too high to go to an operation, or for example, for the patient to relieve it from a pruritus. Is that indication prior to surgery that's completely different from a palliative indication? And then also consider nowadays many patients are pretreated chemotherapeutic. So that might also be the reason for stenting. So so far, get your diagnostic fixed. Do know what the location is and really be informed about the indication. And then we go to the biliary stenting. I think there is really a nice guideline recently published January and very good data for me personally, a very special date reached a certain age there. But that's, of course, of the records. This really guideline is, I would say, very comprehensive and very useful. And I will use quite some of the data from it. And before I do so, I go back a bit back in time. This is from 2010. So quite way back. And this was one of the trials where we said, do we have to drain before we go to surgery in patients with obstructive jaundice? And there was particularly focused on pancreatic carcinoma. And what we actually found there that if we dive in as endoscopist, we can do quite a bit of harm. And if you look at this in particular, this is the preoperative biliary drainage and this is the surgery. And you see that we did quite many complications in the patients that did go for a preoperative biliary drainage. Then there were some suggestions. OK, fine. It's a well-designed randomized control trial, but you probably should have used metal stents instead of plastics. And of course, it shouldn't be the Netherlands. And we did that. We made an additional arm. And then you see to the left, to the right side of your screen, and that we also put in metal. And then you saw that the complication rate went down, but straight away going for surgery can still have his advantage. You have to be very patient with the mouse. That's not my normal character. And then what is actually stated in this guideline, I think that really makes sense. We suggest against routinely preoperative biliary drainage. That means that sometimes there might be an indication, for example, if your patient goes for neoadjuvant treatments. But so not for all patients, you should train up front. Another thing that this guideline is stating, you first should confirm that there is a malignancy, especially if you place an uncovered stent. They do get in, they don't get out easily. And then another thing, if you're going to place an uncovered metal stent, really be aware that you're one and a half centimeters below the hylum. If you don't, your surgeons are really not going to like you. So I would say, if you talk about extrahepatic malignancies, nowadays, in principle, there's no place for plastic. Go for metal if you need drainage at all. Then we have some for the benign indications. In the benign indications, it's recommended to use fully covered stents and actually over multiple plastic stents, according to this guideline. There is one but, and that is especially if the gallbladder is still inside you, then you might consider to use multiple plastic stents. Then we get to the more difficult part. And in my opinion, that's the perihylar malignant and benign strictures. This really requires to be very well prepared what you're going to do. So when do you have to drain? You have to drain if patients do have complaints like pruritus or cholangitis, and if there might be because of the need for a treatment, surgery or chemotherapeutics. Also here, do not just drain because the bilirubin is slightly elevated. Then if you check the root ESCP or PTCD, they are equal if you check the literature. I think nowadays many people do though prefer the ESCP. EOS-guided is a new kit on the block, but I would say that's not common practice yet. You should go for at least 50% drainage of your liver and check what's the future remnant liver is. That's the part you have to drain. And then you have to check if you have to drain. That should stay vital. And then they have also some suggestions in this guideline. They say there's not enough data to go either for plastic or for uncovered. But I also think that's really nice here stated that if you go for drainage and you might consider in the future to place metal, first check with the plastic stent if it's going to work. My personal experience is if you put immediately in metal and it's not the right way, then you're really into a bit of trouble. So for this, for the perihilar, I would say I love plastics. If you see that it's working, then also in a palliative state, you might switch to uncovered metal stents. So in summary, I come back what I started with. Do your diagnostics properly. Benign or malignant tissue is the issue. Know what the location is. That really matters for your future planning. Can you use metal? Are you going to use plastic? Check the indication, not just run into the patient, but is it really needed? And then in short, extra hepatic means fully covered or uncovered metal stents and intra-hepatics, I really would consider to start with plastics. Thanks for your attention.

biliary stenting

diagnosis

multidisciplinary approach

metal stents

perihilar strictures