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  • Review Article
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Endoscopic management of hilar cholangiocarcinoma

Abstract

Hilar cholangiocarcinoma has a poor prognosis and surgery remains the only curative option. However, few patients are diagnosed at a curable stage and palliative therapies are, therefore, mandatory. Endoscopy could have a useful role in the work-up of patients with hilar cholangiocarcinoma who are unsuitable for surgery. Endoscopic retrograde cholangiopancreatography provides an opportunity to collect specimens for cytological or histological diagnosis, yet is often nondiagnostic. Other techniques, including fluorescence in situ hybridization, confocal laser endomicroscopy and endoscopic ultrasonography, are now improving the accuracy of tissue diagnosis. This Review presents an overview of the diagnostic and therapeutic role of endoscopic procedures in the management of hilar cholangiocarcinoma. The use of such procedures in guiding the therapeutic management of patients with hilar cholangiocarcinoma is discussed, and the relative success of endoscopic stenting as the main palliative therapy for obstructive jaundice (a common complication of hilar cholangiocarcinoma) is described. The potential role of photodynamic therapy as a palliative treatment for patients with hilar cholangiocarcinoma is also outlined.

Key Points

  • Endoscopic retrograde cholangiopancreatography (ERCP) enables the collection of tissue specimens from patients with hilar cholangiocarcinoma who are unsuitable for surgery

  • Fluorescence in situ hybridization and confocal laser endomicroscopy could improve the accuracy of diagnosis of malignancy in patients with hilar strictures

  • The choice between percutaneous and endoscopic biliary drainage should be based on the local availability of relevant expertise

  • ERCP should not to be performed in patients with hilar strictures who can be referred for surgery

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Figure 1: Extensive (dominant) stricture of the common hepatic duct identified during endoscopic retrograde cholangiopancreatography in a patient with primary sclerosing cholangitis.
Figure 2: Hilar cholangiocarcinoma as seen by MRI.
Figure 3: Palliative biliary drainage of inoperable hilar cholangiocarcinoma during ERCP.
Figure 4: Placement of expandable metal stents in a patient with extensive hilar cholangiocarcinoma.

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A. Parodi, D. Fisher and M. Conio wrote the manuscript. All authors contributed to researching the data for the article, discussions of the article content and review and/or editing of the manuscript before submission.

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Correspondence to Massimo Conio.

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Parodi, A., Fisher, D., Giovannini, M. et al. Endoscopic management of hilar cholangiocarcinoma. Nat Rev Gastroenterol Hepatol 9, 105–112 (2012). https://doi.org/10.1038/nrgastro.2011.271

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