ACG focuses on diagnosis, drainage of biliary strictures in new clinical guideline
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A new ACG clinical guideline provides evidence-based recommendations for the diagnosis and management of patients with extrahepatic and perihilar biliary strictures, according to a report in The American Journal of Gastroenterology.
“The appropriate diagnosis and management of biliary strictures has important implications in endoscopic, surgical and oncological decision-making, and despite advances in care, remains a major clinical challenge,” Jennifer Maranki, MD, MSc, FASGE, professor of medicine and director of endoscopy at Penn State Hershey Medical Center, told Healio. “We sought to provide guidance to gastroenterologists based the available body of literature, with key shifts in diagnosis and management based on currently available modalities and tools.”
Using the PICO (population, intervention, comparator and outcomes) formula, Elmunzer and colleagues created 11 evidence-based recommendations for this patient population, focusing on the standard goals of care — diagnosis and drainage.
Diagnosis
According to researchers, a “priority of care” in the evaluation of a biliary stricture is safe, accurate and expedient diagnosis.
“Traditionally, [endoscopic retrograde cholangiopancreatography ]ERCP has been the mainstay of tissue acquisition; however, EUS-guided sampling has significantly improved our diagnostic capabilities with substantially less risk and has thus supplanted ERCP in several scenarios,” B. Joseph Elmunzer, MD, MSc, of the division of gastroenterology and hepatology at the Medical University of South Carolina, and colleagues wrote. “Despite important advances in the last two decades, however, the diagnosis of biliary strictures without an associated mass remains a major challenge in clinical practice.”
Highlights for the diagnosis of biliary strictures include:
- Endoscopic ultrasound (EUS) with fine-needle sampling (aspiration or biopsy) is the preferred evaluation method for malignancy over ERCP in patients with an extrahepatic biliary stricture due to apparent or suspected pancreatic mass.
- EUS with fine-needle biopsy or EUS with fine-needle aspiration (FNA) combined with rapid on-site evaluation (ROSE) is recommended over FNA without ROSE for tissue acquisition in patients with an extrahepatic biliary stricture due to apparent or suspected pancreatic mass.
- Multimodality sampling is recommended over brush cytology alone at the time of initial ERCP in patients with suspected malignant perihilar stricture.
Drainage
Restoration of the physiologic flow of bile into the duodenum is the main objective in the management of patients with biliary strictures, regardless of location. However, Elmunzer and colleagues cited “substantial variability” in difficulty and risk for adequate drainage, depending upon the stricture location and complexity.
They continued: “The goals of drainage should be to alleviate symptoms (when present), to reduce serum bilirubin to a level at which chemotherapy can be safely administered (typically 2.5-3.5 mg/dL) and to optimize surgical outcomes in certain scenarios.”
Highlights for biliary stricture drainage include:
- Routine preoperative biliary drainage is not recommended in patients with extrahepatic stricture due to resectable pancreatic cancer or cholangiocarcinoma. However, in select patients, including those with acute cholangitis, severe pruritis or high serum bilirubin levels or those undergoing neoadjuvant therapy or other surgical delays, preoperative drainage is warranted.
- Self-expanding metallic stent placement is recommended over plastic stent placement in patients with a malignant extrahepatic stricture that is either unresectable or borderline unresectable.
- Use of adjuvant endobiliary ablation, either photodynamic therapy or radiofrequency ablation, with plastic stent placement is recommended over plastic stent placement alone in patients with perihilar stricture due to cholangiocarcinoma who are not eligible for resection or transplantation.
- EUS-guided biliary access/drainage is recommended over percutaneous transhepatic biliary drainage in patients with a biliary stricture, in whom ERCP is indicated but unsuccessful or impossible. This recommendation is based on fewer adverse events when performed by endoscopists experienced in these EUS procedures.
“In this guideline, we did our best to identify the more important areas for future research to advance the field. Indeterminate biliary strictures can be a diagnostic challenge and there are exciting opportunities to understand how new technologies, such as AI, can be used to improve our assessment of this difficult condition,” Anna Tavakkoli, MS, MSc, assistant professor of internal medicine at the University of Texas Southwestern, said. “In addition, we highlighted several controversies around the drainage of perihilar strictures, including whether to use ERCP vs. percutaneous drainage, whether metallic or plastic stents are better, and what the optimal stent placement should be.”
Victoria Gómez, MD, FASGE, associate professor of medicine at Mayo Clinic in Jacksonville, Florida, added, “The work up of biliary strictures is complicated, invasive and costly, requiring multiple diagnostic modalities for tissue acquisition with highly variable yields. Providers caring for these patients must be up to date with the most current evidence so that they can make the safest and most well-informed decisions for their patients.
“Considerations such as limiting the use of anesthesia, using modalities that will result in the highest diagnostic yield and providing effective therapies to decompress biliary obstruction, are discussed in this guideline.”
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