Non-surgical Therapy for Unresectable Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma (HCCA) is characterised by late clinical symptoms. As a consequence, most patients will not undergo surgery, and palliation is the main goal of therapy. For the few patients that undergo potentially curative surgery, the need for preoperative biliary drainage (PBD) continues to be debated and remains controversial, as there are many reports with conflicting results. For the palliation of unresectable HCCA, endoscopic or percutaneous transhepatic drainage (PTD) is typically preferred over surgical palliative resection. PTD can be useful in patients with altered anatomy, as a guide to endoscopic procedures (rendezvous technique), after failure of endotherapy or as a rescue therapy for the drainage of segments that have been opacified by endoscopy. Endoscopic palliative bile duct drainage can be performed with plastic stents (PSs) or self-expandable metal stents (SEMSs). Several studies have compared PSs and SEMSs for the palliation of HCCA, and all have been in favour of SEMS placement, which is associated with a lower number of reinterventions, superior cumulative stent patency and even improved survival. The optimal technique for endoscopic palliative metal stent placement and the benefits of bilateral versus unilateral stenting remain controversial and highly debated. Drainage of only 25-30% of the liver volume may be sufficient to ameliorate jaundice in most cases of HCCA. However, reports of bilateral drainage are associated with longer stent patency, lower reintervention rates and, perhaps, a better quality of life for patients. Furthermore, newly available stents may be associated with higher rates of technical success and increasing successful reintervention rates in bilateral stenting.