Selective MRCP and CT-Guided Drainage of Malignant Hilar Biliary Obstruction

Hilar tumors represent a complex disease process with potentially poor outcomes. Curative options in patients with hilar tumors are limited. Successful palliation by providing effective drainage is often the principal intervention, and success can offer substantial improvement in quality of life. Their complexity and location make hilar tumors challenging for the endoscopist. The traditional approach of opacifying the entire biliary tract with contrast increases the risk of infectious complications or requires placement of multiple stents, which is often not feasible. Computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) with reconstructed images are essential noninvasive tools that provide an excellent roadmap of hilar tumors. The information provided can help in guiding the endoscopist to selectively access the optimal intercommunicating ducts for opacification and drainage. In this review, we discuss the approach to endoscopic retrograde cholangiography in hilar tumors, including use of CT scan and MRCP to aid with selective access and stenting. Intrahepatic duct access is done primarily with guidewires and limited use of contrast material. In general, unilateral placement of a metallic stent is adequate, but in select circumstances, bilateral stents may be required. The approach of targeted drainage appears to decrease complications arising from endoscopic drainage of hilar tumors and allows for effective palliation in most circumstances.