GuidelineASGE guideline on the role of endoscopy in the management of malignant hilar obstruction
Graphical abstract
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:
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SEMSs compared with PSs in patients with a short life expectancy (<3 months) or those who place high value on avoiding repeated interventions.
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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.
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This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.