| 抄録 |
Hilar biliary stricture (HBS) is caused by a heterogeneous group of benign and malignant conditions. The definite diagnosis and proper management of HBS remains a clinical challenge, requiring a multidisciplinary approach. Endoscopic intervention provides not only initial decompression for biliary obstruction but also diagnostic information including tissue acquisition and tumor extension. Endoscopic assessment for HBS can provide important clues in determining operation or other therapeutic options. For unresectable malignant HBS, endoscopic biliary drainage using metallic or plastic stent is an effective palliative measure, and is less invasive. Metal stents are superior in stent patency and more cost effective in patients with survival of greater than 6 months. There have been continuous technological developments and improvements for biliary self-expandable metallic stents (SEMS). Although it seems that unilateral metal stenting achieved similar rates of successful drainage and lower complication rates, bilateral stenting can be performed with a goal of over 50% biliary drainage of liver volume and as a mean of physiologic drainage. Bilateral metal stenting can be performed by side-by-side (SBS), or stent-in-stent (SIS) deployment. Bilateral SIS placement is successfully achieved using by cross-wired SEMS or large cell type SEMS. Bilateral endoscopic revision may be feasible and successful in cases where the primary deployed metal stents are occluded. In addition to biliary drainage, endoscopic intraductal tumor ablation such as photodynamic therapy is possible and it may result in improvement in cholestasis and quality of life, and prolongation of survival. Radiofrequency ablation for the stricture is tried by some groups, also. Although surgery has been the traditional treatment for benign HBS, there is increasing desire for minimally invasive endoscopic management. For benign HBS caused by surgery such as liver transplantation, endoscopic management has become the first line approach. The preferred endoscopic approach is dilation of the stricture and insertion of multiple plastic stents. Fully covered SEMS placement can be an alternative to failed cases with conventional method for benign HBS. In conclusion, various endoscopic procedures by endoscopic experts can provide the effective and safe palliative intervention in patients with hilar biliary stricture. |
