ASGE Recognized Industry Associate (ARIA) Training Program for Medtronic | March 2025-Strictures and Strategies_Malignant Hilar Stricture.Gursimran Kochhar

Strictures and Strategies_Malignant Hilar Stricture.Gursimran Kochhar

Pdf Summary

The document, authored by Dr. Gursimran Kochhar, provides a comprehensive overview of the management of biliary hilar obstructions using endoscopic retrograde cholangiopancreatography (ERCP), particularly in malignant cases. It emphasizes the causes, workup, and strategic interventions in such cases, with a focus on stenting techniques and the evolving landscape of ablative therapies.<br /><br />Biliary hilar obstructions can arise from both malignant causes, such as primary biliary tumors and secondary metastases, and benign causes, including primary sclerosing cholangitis and intra-operative injuries. Accurate diagnosis through laboratory tests, imaging, and tissue sampling is crucial to plan appropriate interventions.<br /><br />Stenting in hilar obstructions is pivotal not only for improving patient quality of life and prognosis but also for enabling oncological treatments. The text discusses the technical challenges and controversies surrounding stenting, influenced by patient heterogeneity and evolving therapies. Plastic and metal stents are compared, with evidence favoring self-expanding metal stents (SEMS) due to their longer patency, fewer complications, and cost-effectiveness.<br /><br />The document details decision-making in choosing unilateral vs. bilateral stenting. Traditional practices favored unilateral stenting; however, newer data indicate the need for draining more than 50% of the liver to prevent jaundice.<br /><br />Radiofrequency ablation appears promising, offering substantial tumor remediation and increased stent patency without serious adverse events. This is supported by recent studies indicating improved survival rates in patients with malignant biliary strictures.<br /><br />In practical guidance, the author stresses pre-procedural planning with cross-sectional imaging, careful stent selection, and multidisciplinary collaboration, highlighting the complexity and variability in hilar stenting. The document concludes with case studies illustrating the practical application of these strategies in complex clinical scenarios. Overall, it underscores the necessity of tailored, skilled approaches in managing biliary hilar obstructions to optimize patient outcomes.

Keywords

biliary hilar obstructions

endoscopic retrograde cholangiopancreatography

malignant cases

stenting techniques

ablative therapies

self-expanding metal stents

radiofrequency ablation

unilateral vs. bilateral stenting

pre-procedural planning

multidisciplinary collaboration