Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Preoperative biliary drainage with self-expanding metal stents (SEMSs) brings liver function within an acceptable range in preparation for neoadjuvant therapy (NATx) and provides relief of obstructive symptoms in patients with pancreatic cancer. We compared fully-covered SEMSs (FCSEMSs) and uncovered SEMSs (UCSEMSs) for sustained biliary drainage before and during NATx.

Patients with pancreatic cancer and planned NATx who need treatment of jaundice and/or cholestasis before pancreaticoduodenectomy were randomized to FCSEMSs versus UCSEMSs. The primary endpoint was sustained biliary drainage, defined as the absence of reinterventions for biliary obstructive symptoms, and was assessed from SEMS placement until curative intent surgery or at 1 year.

The intention-to-treat population included 119 patients (59 FCSEMSs, 60 UCSEMSs). Sustained biliary drainage was equally successful with FCSEMSs and UCSEMSs (72.2% vs 72.9%, noninferiority P = .01). Reasons for FCSEMS and UCSEMS failure differed significantly between the groups and included tumor ingrowth in 0% versus 16.7% (P < .01), and stent migration in 6.8% versus 0% (P = .03), respectively. Serious adverse event rates related to stent placement were not significantly different in both groups (23.7% [14/59] vs 20.0% [12/60], P = .66), as were acute cholecystitis rates when the gallbladder was in situ (9.3% [4/43] vs 4.8% [2/42], P = .68) for FCSEMSs and UCSEMSs, respectively. In our study, independent of stent type, predictors of reinterventions were 4-cm stent length and presence of the gallbladder.

FCSEMSs and UCSEMSs provide similar preoperative management of biliary obstruction in patients with pancreatic cancer receiving NATx, but mechanisms of stent dysfunction depend on stent type, stent length, and presence of the gallbladder. (Clinical trial registration number: NCT02238847.).

Preoperative biliary drainage in patients with periampullary tumors and jaundice has been popularized to improve the quality of life and minimize the risks associated with subsequent radical surgery. The aim of this study was to investigate the possible superiority of self-expandable metal stents (SEMS) over plastic stents, by comparing the amount of bacteria in intraoperatively collected bile and using this variable as a proxy for the efficacy of the respective biliary drainage modalities.

In this randomized clinical trial, 92 patients with obstructive jaundice were enrolled; 45 were allocated to the plastic stent group and 47 to the SEMS group. The primary outcome was the extent and magnitude of biliary bacterial growth at the time of surgical exploration. Secondary outcomes were: macroscopic grading of inflammation of the stented bile ducts, occurrence of adverse events after stenting, stent dysfunction, recognized surgical complexities, and incidence of postoperative complications.

 The patients were well matched regarding clinical and disease-specific characteristics. At surgery, there were no group differences in the bacterial amount and composition of the bile cultures or the perceived difficulty of surgical dissection. During the preoperative biliary drainage period, more instances of stent dysfunction requiring stent replacement were recorded in the plastic stent group (19 % vs. 0 %; P  = 0.03). Postoperative complications in patients who underwent curative surgery were more common in patients with plastic stents (72 % vs. 52 %), among which clinically significant leakage from the pancreatic anastomoses seemed to predominate (12 % vs. 3.7 %); however, none of these differences in postoperative adverse events reached statistical significance.

 This randomized clinical study was unable to demonstrate any superiority of SEMS in the efficacy of preoperative bile drainage, as assessed by the amount of bacteria in the intraoperatively collected bile. However, some data in favor of SEMS were observed among the clinical secondary outcomes variables (preoperative stent exchange rates) without increases in local inflammatory reactions.

Early diagnosis and accurate staging of pancreatic cancer is very important to plan optimal management strategy. Endoscopy plays an important role in the diagnosis and management of pancreatic cancer. Endoscopic ultrasound imaging (EUS) is the most sensitive modality for diagnosis, especially for small pancreatic tumors; it also allows tissue acquisition for histological diagnosis. Computed tomography scanning and EUS play complementary roles in staging and are comparable in determining resectability. Endoscopic retrograde cholangiopancreatography allows tissue sampling but is limited to palliative biliary drainage in most cases. In this article, we review the role of endoscopy in the diagnosis and management of pancreatic adenocarcinoma, with special emphasis on the use of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP).

Preoperative biliary drainage (PBD) with stent placement has been commonly used for patients with malignant biliary obstruction. In PBD, the placement of fully covered self-expandable metal stents (FCSEMSs) may provide better patency duration and a lower incidence of cholangitis compared with plastic stents. We aimed to evaluate which type of stent showed better outcomes in PBD.

In this multicenter, prospective randomized trial, we compared PBD with FCSEMSs versus plastic stents in 86 patients with malignant biliary obstruction between January 2012 and December 2014. Patients with obstructive jaundice were randomly assigned to undergo PBD either with plastic stents or FCSEMS placement.

Baseline characteristics were not significantly different between the 2 groups. Endoscopic stent placement was technically successful in all patients. Procedure-related adverse events were not significantly different between the 2 groups (plastic vs FCSEMS group; 16.3% vs 16.3%, P = 1.0). Reintervention was required in 16.3% of the plastic stent group and 14.0% of the FCSEMS group (P = .763). The interval to surgery after PBD (plastic vs FCSEMS group; 14.2 ± 8.3 vs 12.3 ± 6.9 days, P = .426) was not significantly different between groups. Surgery-related adverse events occurred in 43.6% of the plastic stent group and 40.0% of the FCSEMS group (P = .755).

In patients with resectable malignant biliary obstruction, the outcomes of PBD with plastic stents and FCSEMSs were similar. Considering the cost-effectiveness, PBD with plastic stents may be preferable to FCSEMS placement. (Clinical trial registration number: NCT01789502.).

Recent studies suggest that there is no significant benefit and that there may be significantly higher morbidity rates in pancreatic cancer patients who undergo preoperative plastic stent placement for obstructive jaundice. This review attempts to define the role of stenting in patients with pancreatic cancer and malignant obstructive jaundice. The latter includes patients unresectable for cure, those who are too frail to withstand an operation, the occasional patient who presents with cholangitis, and those patients who will have a significant delay in surgery because of preoperative neoadjuvant therapy.

Literature review. A therapeutic endoscopy team member of a multidisciplinary team which evaluates and treats >250 pancreatic cancer patients yearly.

There are 5 historical randomized controlled trials (RCTs) and 1 current RCT demonstrating no significant benefit in preoperatively decompressing jaundiced patients with pancreatic malignancy with percutaneously placed tubes or endoscopically inserted plastic stents. There are 5 RCTs defining a longer patency rate with self-expandable metal stents (SEMS) compared to plastic prostheses suggesting that in the setting of palliation as well as the use of neoadjuvant therapy for resectable or borderline resectable patients, SEMS placement is preferable.

Despite data demonstrating lack of efficacy and potential harm in decompressing the biliary tree as opposed to early surgery in jaundiced patients with pancreatic malignancy, endoscopic retrograde cholangiopancreatography with SEMS insertion remains an invaluable palliative modality in non-resectable patients as well as those in whom contemplated resection is delayed in order to give neoadjuvant therapy.

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) has shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depends on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, percutaneous or surgical treatments are appropriate. Endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction.

Controversy exists regarding whether to place a plastic or a metal endobiliary stent in patients with resectable pancreatic cancer who require biliary drainage. Although self-expandable metal stents (SEMS) provide better drainage compared with plastic stents, concerns remain that SEMS may compromise resection and increase postoperative complications. Our objective was to compare surgical outcomes of patients undergoing pancreaticoduodenectomy (PD) with SEMS in place vs. plastic endoscopic stents (PES) and no stents (NS).

We performed a retrospective analysis from a prospective database of all patients undergoing either attempted or successful PD with SEMS, PES, or NS in place at the time of operation. Patients were compared with regard to perioperative complications, margin status, and the rate of intraoperative determination of unresectability.

A total of 593 patients underwent attempted PD. Of these, 84 patients were locally unresectable intraoperatively and 509 underwent successful PD, of which 71 had SEMS, 149 had PES, and 289 had NS. Among patients who had a preoperative stent, SEMS did not increase overall or serious postoperative complications, 30-day mortality, length of stay, biliary anastomotic leak, or positive margin, but was associated with more wound infections and longer operative times. In those with adenocarcinoma, intraoperative determination of local unresectability was similar in the SEMS group compared with other groups, with 16 (19.3%) in SEMS compared with 29 (17.7%) in PES (P=0.862), and 31 (17.5%) in NS (P=0.732).

Placement of SEMS is not contraindicated in patients with resectable pancreatic cancer who require preoperative biliary drainage.

In this review of the literature, we analyze the indications for preoperative drainage in jaundiced patients who are candidates for pancreaticoduodenectomy (PD) or major hepatectomy due to periampullary or proximal bile duct neoplasms.

The aim of this study is to review the literature and to report on the current management of jaundiced patients with periampullary or proximal bile duct neoplasms who are candidates for PD or major liver resection.

Jaundiced patients represent a major challenge for surgeons. Alterations and functional impairment caused by jaundice increase the risk of surgery; therefore, preoperative biliary decompression has been suggested.

A literature review was performed in the MEDLINE database to identify studies on the management of jaundice in patients undergoing PD or liver resection. Papers considering palliative drainage in jaundiced patients were excluded.

The first group of papers considered patients affected by middle-distal obstruction from periampullary neoplasms, in which preoperative drainage was applied selectively. The second group of papers evaluated patients with biliary obstructions from proximal biliary neoplasms. In these cases, Asian authors and a few European authors considered it mandatory to drain the future liver remnant (FLR) in all patients, while American and most European authors indicated preoperative drainage only in selected cases (in malnourished patients and in those with hypoalbuminemia, cholangitis or long-term jaundice; with an FLR < 30% or 40%) given the high risk of complications of drainage (choleperitoneum, cholangitis, bleeding, and seeding). The optimal type of biliary drainage is still a matter of debate; recent studies have indicated that endoscopy is preferable to percutaneous drainage. Although the type of endoscopic biliary drainage has not been clearly established, the choice is made between plastic stents and short, covered, metallic stents, while other authors suggest the use of nasobiliary drainage.

: A multidisciplinary evaluation (made by a surgeon, biliary endoscopist, gastroenterologist, and radiologist) of jaundiced neoplastic patients should be performed before deciding to perform biliary drainage. Middle-distal obstruction in patients who are candidates for PD does not usually require routine biliary drainage. Proximal obstruction in patients who are candidates for major hepatic resection in the majority of cases requires a drain; however, the type, site, number, and approach must be defined and tailored according to the planned hepatic resection. Recently, the use of preoperative biliary drainage limited to the FLR has been a suggested strategy. However, multicenter, randomized, controlled trials should be conducted to clarify this issue.

Neoadjuvant therapy is increasingly utilized for pancreatic cancer patients to decrease tumor burden in anticipation of later surgical resection. However, infectious complications such as life threatening cholangitis may occur for those with biliary obstruction. We hypothesized that placement of metal rather than plastic stents in such patients results in lower rates of stent-related complications, leading to improved clinical outcomes.

Retrospective cohort of pancreatic cancer patients treated by the University of Michigan Multidisciplinary Pancreatic Cancer Destination Program between January 2005 and June 2010. Only patients undergoing neoadjuvant therapy with one or more biliary stents placed for malignant obstruction were studied. Time to stent complication was compared between metal and plastic stents. The complication rate was estimated as the ratio of complications to total stent exposure time and 95% confidence intervals were calculated.

52 patients met inclusion criteria. A total of 113 stents were placed in 52 patients (70 plastic, 43 metal). The complication rate was almost 7 times higher with plastic stents, 0.20 (95% CI, 0.14-0.30), than with metal stents, 0.03 (95% CI, 0.01-0.06). Moreover, the rate of hospitalization for stent-related complications was 3-fold higher in the plastic stent group than the metal stent group. The first quartile estimate of time to stent complication was almost 5 times longer for metal than for plastic stents (44 vs. 200 days) (P<0.0001).

Compelling evidence indicates that self-expanding metal, not plastic stents should be used for malignant biliary obstruction in patients undergoing neoadjuvant therapy for pancreatic cancer.

Increasing numbers of patients with resectable pancreatic cancer are receiving neoadjuvant therapy. Biliary drainage with plastic stents during this period can be associated with recurrent episodes of stent occlusion resulting in unplanned ERCPs and interruptions in therapy.

To evaluate the efficacy and safety of self-expandable metal stents (SEMSs) during the neoadjuvant period for resectable pancreatic cancer.

Patients with proven pancreatic adenocarcinoma with biliary obstruction underwent placement of SEMSs, and data on stent patency and complication rates were collected prospectively.

Tertiary-care referral center.

This study involved 55 patients with resectable and borderline resectable pancreatic duct adenocarcinoma who were recruited between March 2009 and December 2010.

SEMSs were placed for biliary decompression. The shortest length of stent required to bridge the stricture was used so as to leave enough of the normal bile duct above the stent available for subsequent surgical anastomosis. Endoscopic reintervention was performed in those with stent malfunction. Stents were not removed before surgery.

Stent patency rate during the neoadjuvant period, stent malfunction rate, and complication rates. Information on stent-related difficulties, if any, during surgery.

Fifty-five patients were recruited (29 men, 26 women; age, mean [± SD] 65.9 ± 11 years; resectable 23, borderline resectable 32). Median time for neoadjuvant therapy and restaging before surgery was 104 days (range 70-260 days). At the median time of 104 days, 88% of SEMSs remained patent. By 260 days, stent malfunction occurred in 15% of patients. These included stent occlusion in 13% and stent migration in 2%. SEMS malfunction occurred in 3 of 27 patients (11%) who ultimately underwent pancreaticoduodenectomy and in 5 of 21 patients (24%) with disease progression (P = not significant). The presence of SEMSs did not interfere with pancreaticoduodenectomy in any patients who underwent surgery.

Nonrandomized study.

SEMSs are effective and safe in achieving durable biliary drainage in patients with pancreatic cancer receiving neoadjuvant therapy. It is not necessary to remove SEMSs before surgery if the shortest length of stent required to bridge the stricture is used.

Endoscopic therapy is essential in the management of malignant and benign biliary strictures. With new advancements in biliary stent technology and the many controversies surrounding biliary stenting, managing biliary strictures is not always straightforward. The purpose of this article is to review the major issues surrounding biliary stenting, summarize current treatment strategies, discuss advancements in stent technologies, and describe emerging indications of biliary stents.

Pancreatic cancer continues to be a diagnostic and therapeutic challenge. The advent of endoscopic ultrasound-guided interventions have brought about a paradigm shift in the endoscopic approach to diagnosis, treatment and palliation of this common malignancy. The last decade has witnessed significant advances in techniques of endoscopic biliary drainage, endoluminal stenting, celiac plexus neurolysis and image-guided radiation therapy, which have transformed the scope of palliation in pancreatic cancer. Moreover, endoscopic ultrasound-aided intratumoral delivery of fiducials, radioisotopes and chemotherapeutic agents have shown promising results and warrant further investigation. This review summarizes the recent advances in endoscopic applications for the management of pancreatic neoplasms.

To study pre-operative and peri-operative course and outcome on follow up after pancreaticoduodenenctomy (PD) for resectable pancreatic cancer amongst patients receiving self-expanding metal stents (SEMS).

Medical charts of consecutively reviewed patients (2005-2009) with resectable pancreatic cancer and SEMS placement before PD at the MD Anderson Cancer Center (MDACC) were studied.

Seventy-nine patients (mean age, 68 ± 9 years; 54% males) undergoing PD after SEMS placement were analyzed. Of these, 70% (55/79) had come with previous plastic stents placed within a median of 29 (5-216) days because of presentation and most (95%) underwent neoadjuvant chemoradiation after SEMS placement. The median interval between SEMS placement and PD was 120 (range 28-306) days. There were no technical difficulties during PD. The resected tumor was stage T3 in 72 patients, positive node in 44, lymphovascular invasion in 47, and perineural invasion in 62. Within 30 days after surgery, 26 (33%) patients developed complications requiring intervention, but none died. During a median follow-up of 349 (14-1,508) days after surgery, 32 (41%) patients developed metastatic disease, and 20 (25%) died; median survival was approximately 3 years. Development of metastatic disease during follow-up independently predicted survival with hazard ratio of 16 (95% CI: 4-68; P = 0.0001).

Contrary to the tendency of avoiding the use of metal stents for biliary decompression amongst patients with resectable pancreatic cancer, our study demonstrated that SEMS did not adversely affect surgical technique, postoperative course, or long-term outcome. Therefore, metal stents should be considered for patients with resectable pancreatic cancer who will undergo preoperative chemoradiation.

Limited data exist regarding fully-covered, self-expandable metal stents (CSEMS) with anchoring fins for the management of malignant distal biliary strictures. The aim of this study is to evaluate their safety and patency.

Over a period of 2 years, 70 patients (45 males, 66 ± 13 years) underwent endoscopic retrograde cholangiopancreatography (ERCP) with placement of a 10-mm (67 patients) or 8-mm diameter (3 patients) CSEMS for the palliation of distal malignant biliary obstruction (pancreatic [53] or other [17]). Data were collected prospectively for survival and stent patency; complications were evaluated retrospectively.

After CSEMS placement, 17 patients proceeded to surgery, and 53 patients were deemed unresectable. Mean survival for non-surgical candidates was 180 days (range: 15-1091), and 170 days (range: 9-589) for patients who underwent surgical management. CSEMS were left in place and remained patent for a mean of 163 days (range: 15-1091) in non-surgical candidates, and a mean of 55 days (range: 5-126) in surgical candidates. Complications during placement included wire perforations (4) and proximal deployment requiring repositioning (4), one of which was complicated by a bile leak. Post-procedure complications were observed in 24 cases (34%) and included post-ERCP pancreatitis (8, with 2 of them severe), post-procedure pain (5, with 3 requiring admission), cholecystitis (3), stent occlusion (3), cholangitis (2), proximal migration (1), post-sphincterotomy bleeding (1), and sepsis leading to death (1).

CSEMS appear to provide acceptable short-term patency rates; however, their limited long-term patency and high complication rate might limit their widespread use. Further long-term prospective data are required to confirm this observation.

It is unclear whether plastic or metal stents are more suitable for preoperative biliary decompression in pancreatic cancer. The objective of this study was to compare the rate of endoscopic reinterventions in patients with pancreatic cancer undergoing plastic or self-expandable metal stent (SEMS) placements for preoperative biliary decompression.

This was a retrospective study of all patients with obstructive jaundice secondary to pancreatic head cancer who underwent their index endoscopic retrograde cholangiopancreatography (ERCP) and all follow-up biliary stent placements at our center before undergoing pancreaticoduodenectomy. Plastic or SEMS were placed at ERCP for biliary decompression. The main outcome measure was to compare the rate of endoscopic reinterventions between the plastic and SEMS cohorts.

29 patients who underwent pancreaticoduodenectomy had preoperative biliary stent placement (18 plastic, 11 SEMS) at our center. Whereas none of the 11 patients who underwent SEMS placement had stent dysfunction, 7 of 18 (39%) patients with plastic stents required endoscopic reintervention before surgery (P=0.02). Reinterventions were due to cholangitis (n=1) or persistent elevation in serum bilirubin levels (n=6). Two patients with SEMS underwent EUS-guided fine-needle aspiration after ERCP, which yielded a positive diagnosis of cancer in all cases; SEMS did not impair visualization of the tumor mass at EUS. Pancreaticoduodenectomy was undertaken successfully in all 29 patients and the presence of a SEMS did not interfere with biliary anastomosis. On univariate logistic regression, only SEMS placement was associated with less need for endoscopic reintervention (P=0.02).

SEMS are superior to plastic stents for preoperative biliary decompression in pancreatic cancer.

Determine the stent patency rates, need for additional procedures, and complications of plastic biliary during neoadjuvant chemoradiotherapy.

Malignant biliary obstruction is a common feature of pancreatic ductal adenocarcinoma and palliative plastic biliary stents are often placed during neoadjuvant chemoradiotherapy before operative resection.

Forty-nine patients with resectable or locally advanced pancreatic adenocarcinoma and biliary obstruction had a plastic biliary stent placed endoscopically before receiving neoadjuvant chemoradiotherapy. The median time from stent placement to surgery was 150 days (range 71-227 d). Twenty-two patients (45%) had stents that remained patent throughout the course of neoadjuvant therapy. The remaining 27 patients (55%) required repeat ERCP for stent exchange, a median of 82.5 days after original stent placement (range 14-183 d). Fourteen were owing to abnormal liver enzymes or jaundice and 13 were owing to ascending cholangitis. Seventeen of these patients (63%) required hospitalization for either biliary obstruction or cholangitis. The median duration of hospital stay associated with stent exchange was 3 days (range 2-13 d).

Plastic biliary stents do not maintain patency during the time required for most patients to complete neoadjuvant chemoradiotherapy for pancreatic adenocarcinoma. Initially placing metallic stents to palliate malignant obstruction may be a safer and more cost-effective strategy.

The British Society of Gastroenterology guidelines for the management of malignant obstructive jaundice state: "If a stent is placed prior to surgery, this should be of the plastic type and it should be placed endoscopically. Self-expanding metal stents should not be inserted in patients who are likely to proceed to resection." In 2003, a small series of complications after endoscopic intervention caused a change in the authors' practice. Currently, all patients requiring relief of biliary obstruction before surgical resection undergo attempted insertion of a short metal biliary stent.

Retrospective analysis of the authors' prospective database containing all patients presenting with periampullary and pancreatic tumors between January 2004 and May 2008 was performed.

The authors have attempted percutaneous placement of internal metal stents in 67 patients with resectable malignancies and biliary obstruction. Stenting was successful for 53 patients (79%), and 5 patients (9.4%) experienced complications. These five patients were successfully managed conservatively, and all proceeded to trial dissection. The mean bilirubin level was 253 mg/dl before intervention and 33 mg/dl before surgery for the stented patients compared with 308 mg/dl before intervention and 102 mg/dl before surgery for those who needed external drainage.

Percutaneous insertion of short metal stents provides a safe and effective alternative to endoscopic stent placement for treating jaundice preoperatively in patients with potentially resectable tumors around the pancreatic head.

In patients with malignant biliary obstruction considered suitable for surgical resection, preoperative drainage might be expected to improve surgical outcomes by restoring liver function and improving nutritional status. In practice, however, the benefits of preoperative drainage are far from clear. Studies to date have reported differing outcomes, and some have suggested that morbidity and mortality are greater in patients undergoing drainage than in those proceeding directly to surgery. The development of clinical guidelines has been limited by the lack of convincing randomized data, which in turn has led to variations in practice. This article examines the arguments for and against preoperative biliary drainage, the conflicting data on the subject, and the techniques used.

To analyze the role of endoscopy in the diagnosis and treatment of pancreatic adenocarcinoma. New developments, including molecular analysis of endoscopic tissue samples and injection of antitumor agents, are discussed.

Endoscopic ultrasound is superior to multidetector computed tomography for detection of smaller than 3-cm pancreatic tumors, and for T staging, while they are equivalent for nodal staging and assessment of resectability. Molecular analysis of endoscopic ultrasound-guided fine-needle aspiration samples has the potential to improve cancer detection. Placement of biliary self-expanding metal stents prior to Whipple resection appears to be an option to reduce stent obstruction and allow neo-adjuvant therapy. Endoscopic ultrasound-guided biliary drainage is a new approach to patients who failed to have a biliary stent placed by endoscopic retrograde cholangiopancreatography. Contrast-enhanced endoscopic ultrasound may be useful to differentiate focal inflammation from pancreatic carcinoma. Optical coherence tomography was shown to distinguish nonneoplastic from neoplastic main pancreatic duct tissue. Finally, endoscopic ultrasound-guided interstitial brachytherapy and injection of therapeutic agents into tumors have shown exciting preliminary results.

Endoscopic approaches for diagnosis and palliation of pancreatic adenocarcinoma are rapidly expanding. These new techniques show promise in the diagnosis, staging, and treatment of pancreatic malignancy.

Endoscopic retrograde cholangiopancreatography is reserved primarily for therapeutic reasons. Recent literature continues to support therapeutic uses of the technique. This review addresses the literature in the field of biliary endoscopy for the year 2006 and is intended to assist gastroenterologists and gastrointestinal surgeons in everyday practice.

Endoscopic management of choledocholithiasis in gallstone pancreatitis, a newer approach in the endoscopic management of malignant biliary strictures, the broadening therapeutic indications including the use of gallbladder stenting and the performance of endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y gastric bypass are discussed. Safety of the technique continues to be addressed. The risks of pancreatitis after endoscopic retrograde cholangiopancreatography as well as morbidity in the elderly are addressed.

Major updates in the management of biliary tract disease using biliary endoscopy are discussed over a broad range of biliary tract diseases. The literature emphasizes the broadening therapeutic role of endoscopic retrograde cholangiopancreatography as well as improvements in our understanding of risk factors for complications and the potential for their prevention.

Surgical bypass and endoscopic stents are available for palliative bypass of malignant distal biliary obstruction.

Comparison of reported outcomes in randomized controlled trials (RCTs) which included surgery, endoscopic plastic stents or endoscopic metal stents in palliative relief of malignant distal biliary obstruction.

Systematic review and meta-analysis of published literature and conference proceedings review to June 2006.

We found 24 studies, containing 2436 patients, which met our inclusion criteria. Endoscopic stenting with plastic stents (three studies) is associated with a lower risk of complications (RR 0.60, 95% CI 0.45-0.81), but a higher risk of recurrent biliary obstruction (RR 18.59, 95% CI 5.33 -64.86) than traditional surgical bypass. Self-expanding metal stents (seven studies) are associated with a significantly reduced risk of recurrent biliary obstruction at 4 months (RR 0.44, 95% CI 0.3, 0.63), or prior to death or end of study (RR 0.52, 95% CI 0.39-0.69), but are not superior to plastic stents in terms of technical success, therapeutic success, mortality or complications. Cost-effectiveness outcomes were not suitable for meta-analysis. No other plastic stent designs have been demonstrated to be superior to polyethylene stents (12 studies).

Endoscopic metal stents are the intervention of choice in patients with malignant distal biliary obstruction, producing similar outcomes to plastic stents, but with improved patency rates.