Endoscopic Drainage and Ablative Options for Pancreatobiliary Tumors

• Endoscopic biliary drainage with a self-expandable metal stent (SEMS) is the standard of care today.
• More than 50% of liver volume must be drained to effectively palliate and avoid atrophic lobe drainage in multifocal hepatic steatosis (MHS).
• Two or more uncovered SEMS are preferred in high-grade hilar tumors. It is important to prevent contamination of segments that have not been drained.
• EUS-guided choledochoduodenostomy (EUSBD) is preferred if endoscopic retrograde cholangiopancreatography (ERCP) drainage fails or is incomplete.
• Percutaneous transhepatic biliary drainage (PTBD) is a valid option if ERCP fails or in altered anatomy. It is associated with a high success rate (87-100%).
• Intraductal photodynamic therapy (PDT) and possibly endobiliary radiofrequency ablation (eRFA) improve survival.
• Asia Pacific Consensus 2013 advises SEMS for palliation of high-grade MHS if the expected survival of the patient is more than 3 months.
• ESGE Guidelines 2018 recommends uncovered SEMS as a choice of the stent in MHS for palliative drainage.
• ERCP is the first choice for lower-end and Bismuth I and II. However, there is controversy in the route of drainage (ERCP or PTBD) of the advanced MHS.