Strategy in malignant biliary obstruction drainage

Prof. Rungsun Rerknimitr, MD, FRCP (London), FASGE
There are three considerations for drainage strategy in malignant biliary obstruction.
First the Bismuth location, whether it is hilar or non-hilar obstruction. In addition, the advanced Bismuth level of obstruction requires a special attention due to the risk of post injection of contrast induced cholangitis. Second, the liver volume, at least more than half of the liver volume need to be drained to relieve the significant level of bilirubin. Future atrophic lobe and lobe with vascular encasement are to be avoided since this will not reduce the level of bilirubin post drainage. Third, patient life expectancy, those with very short life expectancy metallic stent may not be cost-effective, however plastic-stent patency may be shorter than the patient’s life and the mortality rate from occluded plastic stent in this group is high. Therefore, a careful patient selection for biliary driange is imperative.
To date, self-expandable metallic stent is the more preferred stent for palliative biliary drainage. In addition, in those hilar obstruction who fail adequate drainage from transpapillary approach, EUS guided biliary drainage between intrahepatic duct and stomach or duodenum has become a more popular technique than the percutaneous approach.