ASGE Postgraduate Course at ACG: Innovative Practices for the Endoscopist of Today, Tomorrow and Beyond | October 2023-5

5_ASGE postgrad hilar obstruction

Pdf Summary

The document provides a comprehensive guide on endoscopic management of hilar obstruction, presented during the ASGE Postgraduate Course on October 22, 2023, by Drs. Joanna Law, Swati Pawa, and Andrew Storm.<br /><br />**Disclosures**:<br />Various conflicts of interest are noted, including research grants and consultancy roles with multiple medical and scientific companies.<br /><br />**Outline**:<br />1. Anatomy and approach to hilar obstruction.<br />2. ASGE guideline recommendations on:<br />   - Endoscopic vs percutaneous drainage<br />   - Number of liver segments to drain<br />   - Ideal stent type.<br />3. Emerging techniques and devices for hilar obstruction.<br /><br />**Malignant Hilar Obstruction**:<br />- Differentiates between intrinsic and extrinsic obstructions.<br />- Reports a 5-year survival rate of 10%, with 70% being unresectable.<br />- Diagnostic criteria for hilar cholangiocarcinoma include malignant-appearing stricture and positive biopsy, cytology, or specific biomarkers.<br /><br />**Patient Approach**:<br />- Emphasizes a multidisciplinary consensus for tissue acquisition and drainage.<br />- Imaging aims to assess mass lesions, stage the disease, and plan drainage strategies.<br /><br />**Bismuth Corlette Classification**:<br />- Describes types of hilar involvement and their classifications, impacting resectability and drainage strategy.<br /><br />**Case Discussions**:<br />1. **Case #1**: <br />   - 72M with jaundice; initial ERCP recommended as opposed to PTBD for potentially resectable malignancies.<br />2. **Case #2**: <br />   - 58-year-old with metastatic gastric cancer; guidelines suggest metal stents for poor life expectancy cases and bilateral stents for bilateral obstruction.<br />   - Subsequent reduction of bilirubin levels post-stenting.<br />3. **Case #3**:<br />   - 68-year-old with unresectable cholangiocarcinoma; EUS-HG used for failed ERCP, achieving clinical success albeit with significant adverse events.<br />4. **Case #4**:<br />   - Overview of radiofrequency ablation (RFA). RFA is proposed as an effective alternative to PDT, highlighting technical steps and adverse events.<br /><br />**Summary**:<br />- Emphasizes imaging, multidisciplinary discussion, cautious contrast use, and drainage strategies that avoid atrophic or resectable segments.<br />- Notes different drainage techniques, including endoscopic and percutaneous, and the role of adjunctive therapies in nonoperable strictures.

Keywords

endoscopic management

hilar obstruction

ASGE guidelines

multidisciplinary consensus

Bismuth Corlette Classification

malignant hilar obstruction

ERCP

EUS-HG

radiofrequency ablation

drainage strategies