A modern approach to malignant hilar biliary obstruction

Management of patients with malignant hilar biliary obstruction is challenging for all specialists involved in their care. Evaluation should focus on potential surgical resection, which offers the principal chance of cure; liver transplantation is offered as an experimental treatment at a few centers. Attempt at curative surgical resection is appropriate for selected tumors and often requires partial hepatectomy. Diagnosis and staging is now facilitated by the use of magnetic resonance cholangiopancreatography (MRCP), spiral computed tomography, and endoscopic ultrasonography, which should largely supplant invasive cholangiography. Use of endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography should be limited primarily to palliation of jaundice in patients with unresectable tumors and to establish tissue diagnoses in ambiguous cases. Palliation of jaundice is optimal with self-expanding metallic stents. Safe and effective drainage can be achieved by using MRCP for targeted endoscopic placement of unilateral metal stents in most cases, with bilateral stents rarely required unless undrained ducts are contaminated. Other palliative modalities for bile duct tumors include surgical bypass, intraluminal and external beam radiation therapy, chemotherapy, and photodynamic therapy.