Elsevier

Gastrointestinal Endoscopy

Volume 94, Issue 2, August 2021, Pages 222-234.e22
Gastrointestinal Endoscopy

Guideline
ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction

https://doi.org/10.1016/j.gie.2020.12.035Get rights and content

This clinical guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the management of patients with malignant hilar obstruction (MHO). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses primary drainage modality (percutaneous transhepatic biliary drainage [PTBD] vs endoscopic biliary drainage [EBD]), drainage strategy (unilateral vs bilateral), and stent selection (plastic stent [PS] vs self-expandable metal stent [SEMS]). Regarding drainage modality, in patients with MHO undergoing drainage before potential resection or transplantation, the panel suggests against routine use of PTBD as first-line therapy compared with EBD. In patients with unresectable MHO undergoing palliative drainage, the panel suggests PTBD or EBD. The final decision should be based on patient preferences, disease characteristics, and local expertise. Regarding drainage strategy, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placement of bilateral stents compared with a unilateral stent in the absence of liver atrophy. Finally, regarding type of stent, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placing SEMSs or PSs. However, in patients who have a short life expectancy and who place high value on avoiding repeated interventions, the panel suggests using SEMSs compared with PSs. If optimal drainage strategy has not been established, the panel suggests placing PSs. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

Section snippets

Methods

This guideline document was conceptualized and conducted according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, as previously described.4,5 The American Society for Gastrointestinal Endoscopy (ASGE) Governing Board approved the final document before publication.

Results

Details of the primary recommendations from this guideline document are summarized in Table 1 and the graphical abstract. General management concepts are summarized in Table 2.

Recommendation 1: In patients with unresectable MHO undergoing endoscopic palliative endoscopic stent placement, the panel suggests the following:

  • SEMSs compared with PSs in patients with a short life expectancy (<3 months) or those who place high value on avoiding repeated interventions.

  • PSs compared with SEMSs if an

General concepts

In addition to addressing the above questions, the panel has also provided general concept statements in managing these patients. No systematic reviews were conducted for these statements, and they represent expert opinions of this multidisciplinary panel (Table 2).

A subset of patients undergo liver transplant for MHO. In such cases, general guiding principles include avoiding EUS with FNA of the lesion; avoiding uncovered SEMSs, which may be difficult to remove surgically; and avoiding PTBD

Future directions

This document clearly highlights several gaps in our understanding of the management of MHO. Given the uncertainties outlined above, high-quality randomized and observational data are needed to strengthen existing recommendations and to provide evidence-based guidance in other areas. Regarding the 3 questions addressed in this document, all recommendations are conditional and are based on low-quality evidence. Therefore, additional rigorous investigation addressing prosthesis selection and

Summary and conclusions

In this document, the ASGE offers evidence-based, clinically relevant, practical guidelines addressing management of MHO. This guideline followed the GRADE methodology. The final recommendations offer guidance on stent type, drainage strategy, and drainage modality along with key clinical concepts in the management of patients with MHO. Furthermore, the guideline provides a visual representation of the recommendations, which is aimed at making these recommendations easier to understand and

GUIDELINE UPDATE

ASGE guidelines are reviewed for updates approximately every 5 years, or in the event that new data may influence a recommendation. Updates follow the same ASGE guideline development process.

Disclosure

The following authors disclosed financial relationships: B. Qumseya disclosed no financial relationships. L. Jamil disclosed no financial relationships. B. Elmunzer is a consultant for Takeda Pharmaceuticals. A. Riaz disclosed no financial relationships. E. Ceppa disclosed no financial relationships. N. Thosani is a consultant for Boston Scientific Coporation, TaeWoong Medical; is a consultant and receives research support from PENTAX of America, Inc,; receives royalties from UpToDate; receives

Funding

This guideline was funded exclusively by the American Society for Gastrointestinal Endoscopy; no outside funding was received to support the development of this guideline.

Acknowledgment

The authors are grateful to Patricia Maxin from the Cholangiocarcinoma Foundation for her input as a patient advocate on this guideline panel.

References (39)

  • L. Wang et al.

    A systematic review of the comparison of the incidence of seeding metastasis between endoscopic biliary drainage and percutaneous transhepatic biliary drainage for resectable malignant biliary obstruction

    World J Surg Oncol

    (2019)
  • A.L. Van Dyke et al.

    Biliary tract cancer incidence and trends in the United States by demographic group, 1999-2013

    Cancer

    (2019)
  • W.R. Jarnagin et al.

    Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma

    Ann Surg

    (2001)
  • R. Siegel et al.

    Cancer statistics, 2014

    CA Cancer J Clin

    (2014)
  • S. Wani et al.

    Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer

    Gastrointest Endosc

    (2018)
  • B. Qumseya et al.

    ASGE guideline on screening and surveillance of Barrett's esophagus

    Gastrointest Endosc

    (2019)
  • G.H. Guyatt et al.

    GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

    BMJ

    (2008)
  • T. Sawas et al.

    Self-expandable metal stents versus plastic stents for malignant biliary obstruction: a meta-analysis

    Gastrointest Endosc

    (2015)
  • H.J. Wagner et al.

    Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction. A prospective and randomized trial

    Endoscopy

    (1993)
  • Cited by (31)

    • Déjà vu but with a different conclusion

      2023, Gastrointestinal Endoscopy
    View all citing articles on Scopus

    This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

    View full text