Endoscopic Retrograde Cholangiopancreatography Stenting for Hilar Cholangiocarcinoma

Despite advances in gastrointestinal endoscopic technology, the management of malignant hilar biliary obstruction continues to be a challenge for advanced endoscopists. There has been ongoing debate regarding the optimal modality for both diagnostic and therapeutic interventions in malignant hilar obstruction. Various approaches including endoscopy, interventional radiology guided interventions and surgery are available. The management of malignant hilar biliary obstruction should include a multidisciplinary approach, and both diagnostic and therapeutic interventions should be planned based on whether patient is a candidate for curative surgical resection or not. Understanding the Bismuth-Corlette classification as well as the liver segmental anatomy is crucial for both surgical planning as well as planning endoscopic drainage. Safe and effective endoscopic drainage of malignant hilar biliary obstruction requires a multidisciplinary approach, detailed understanding of liver as well as ductal anatomy, and careful adaptation of any strategy to the individual patient's condition, anatomy, prognosis, and in collaboration with surgery, oncology, and radiology. In this article we review the anatomical concepts and technical considerations that are essential to understand while performing endoscopic retrograde cholangiopancreatography in patients with malignant hilar biliary obstruction.