An Updated Approach to Pancreatic

and Biliary Strictures

B. Joseph Elmunzer, MD
ACG Postgraduate Course 2022
22 October 2022
Conflicts of interest

• No commercial COI
• Clinical ‘expert’ for ASGE guideline on MHO*
• Author for ACG guideline on biliary strictures**
• Author for AGA CPU on endoscopy in RAP and CP***

*Qumseya et al. GIE 2021

**Elmunzer et al. AJG, under review
***Strand & Law et al. Gastro 2022
Biliary strictures
• ~37,000 cases biliary obstruction from Panc Ca
• ~3000 cases of malignant hilar obstruction
• Benign strictures
Fibroinflammatory
 Chronic pancreatitis
 Primary sclerosing cholangitis
 Autoimmune (IgG4-mediated) pancreatitis
 IgG4-mediated cholangitis
 Sarcoidosis
 Recurrent pyogenic cholangitis

Iatrogenic
 Cholecystectomy
 Liver transplantation
 Local cancer treatment (chemoembolization, radiation therapy)
Hilar strictures
• 10-20% of malignant biliary obstruction

• Most commonly cholangiocarcinoma (Klatskin)

- Hepatocellular carcinoma
- Gallbladder cancer
- Metastatic disease (colorectal cancer, breast cancer)

• Benign disease
- PSC
- IgG4 mediated cholangiopathy
- Post-operative
Pancreatic strictures
• Malignancy

• Chronic pancreatitis
(fibroinflammatory)

• Chronic pancreatitis
(pancreaticolithiasis)
Goals of care
• Diagnosis

• Drainage
(restore flow of bile or
pancreatic juice)
Diagnosis of pancreatic & extrahepatic
biliary strictures (with suspected mass)
• Traditional mainstay: ERCP with brush cytology
• EUS + FNA/B >>> ERCP
• Diagnostic accuracy of EUS-FNA: ~80-90%
Recommendation

1. In patients with an extrahepatic biliary stricture due to an apparent or suspected pancreatic mass,

we recommend EUS with fine-needle sampling (aspiration or biopsy; FNA/B) over ERCP as the

preferred method of evaluating for malignancy.

de Moura DTH, et al. Endosc Ultrasound 2018

de Moura DTH, et al. Clin Endosc 2020
Diagnosis of hilar stricture (or extrahepatic
biliary stricture without mass)

• Brush cytology (sensitivity 35-52%, as low as 6%*)

• Forceps biopsies (sensitivity 45-65%)

• Stent cytology (sensitivity 7-35%)

• EUS (sensitivity 25-45%)**

*Draganov et al. GIE 2012

**Without FNB
Most important principle
• Basically every modality adds value to brushing
• Triple sampling (sensitivity 70+%)*

• Multimodality sampling recommended over

brush cytology alone at time of index ERCP

*Baroud et al. GIE 2021

*Nanda et al. Therap Adv Gastroenterol 2015
Advanced diagnostics
Treatment of benign biliary strictures

Balloon dilation

Placement of the maximal number of

plastic stents

Repeat ERCP every so often with stent

stacking

Continue until “fluoroscopic resolution”

of the stricture, 6-12 months

Costamagna et al. GIE 2001

Costamagna et al. GIE 2010
Fully covered metal stents (SEMS) for
benign bile duct stricture
 Fully covered SEMS for BBS
• Similar stricture resolution
• Similar recurrence
• Similar adverse events

• Fewer ERCPs with FcSEMS (at least one less)

• Important caveats (cystic duct, proximity to hilum, PEP)
Cote et al. JAMA 2016
Ramachandani et al. Gastro 2022
Kaffes et al. Ther Adv Gastroenerol 2014
Haapamaki et al. Endoscopy 2015
Tal et al. GIE 2017
Surgery for (painful) obstructive CP
• Three RCTs – 199 participants

Díte et al. Endoscopy 2003

Cahen at al. NEJM 2007
Issa et al. JAMA 2020
Best Practice Advice 4: Surgical intervention should be considered over

endoscopic therapy for long-term treatment of patients with painful

obstructive chronic pancreatitis. Endoscopic intervention is a reasonable

alternative to surgery for suboptimal operative candidates or those who

favor a less invasive approach, assuming they are clearly informed that

the best practice advice primarily favors surgery.

Strand & Law et al. Gastro 2022

Endotherapy for obstructive CP
• Follows paradigm similar to BBS
- Serial ERCP for sequential dilation/stent upsizing (stones)
- Role of fully covered SEMS?*

• 6-12 months of treatment to remodel stricture

• Pain improvement in ~80% (observational)

- Pain from parenchyma/nerves in some fraction of patients**

*Sofi et al. Pancreatology 2021

**PERCePT: NCT04232670
Hilar strictures

• Drainage?
• ERCP or PTC?
• Unilateral vs. bilateral drainage?
• Plastic vs. metallic stents?
• Adjuvant intraductal therapies?
ERCP generally favored
• High success rates for
other types of obstruction
• Safer than PTC
• More comprehensive
tissue sampling
• Avoids external tubes
However...
• Observational data: PTC >> ERCP*
• Recommended for Bismuth 3 & 4 strictures**
• ~40% pivot to PTC after ERCP***

*Paik et al. GIE 2009

*Moole et al. Can J Gastro Hep 2016
*Hameed et al. HPB 2016
**Rerknimitr et al. J Gastroenterol Hepatol 2013
***Wiggers et al. Endoscopy 2015
 Two available RCTs
• Pre-op ERCP vs. PTBD for resectable • ERCP vs. PTBD for unresectable GB
CCA cancer

• 54 pts (terminated) • 54 pts

• No difference in severe complications • PTBD:

(1o outcome) > success
> QoL
• >> mortality in PTBD group < complications

• 50% of ERCP pts  PTBD • No difference in mortality

Coelen et al. Lancet GH 2018
Saluja et al. CGH 2008
PTC vs. ERCP

Al-Kawas et al. Trials 2018

Elmunzer et al. Clin Gastroenterol Hepatol 2021
Unilateral vs. bilateral drainage
• Conflicting evidence
• Meta-analyses suggest no difference*
- included type 1 & 2 strictures

• More complex than unilateral vs. bilateral

*Sawas et al. GIE 2015

*Hong et al. Eur J Gastro Hep 2013
*Puli et al. Ind J Gastroenterol 2013
Wang & Yachimski. Gastro 2018
Clinical Gastrointestinal Endoscopy
3rd Edition Elsevier 2019
Clinical Gastrointestinal Endoscopy
3rd Edition Elsevier 2019
Clinical Gastrointestinal Endoscopy
3rd Edition Elsevier 2019
Unilateral vs. bilateral drainage
• Conflicting evidence
• Meta-analyses suggest no difference*
- included type 1 & 2 strictures

• More complex than unilateral vs. bilateral

• New paradigm necessary in practice and
research

*Sawas et al. GIE 2015

*Hong et al. Eur J Gastro Hep 2013
*Puli et al. Ind J Gastroenterol 2013
Plastic vs. metal stents
• 3 RCTs & meta-analyses demonstrate improved
outcomes associated with SEMS*

• Design limitations in published RCTs

• Long-term outcomes unclear (? burn bridges)

• Impact on PDT & RFA**

*Perdue et al. J Clin Gastro 2008
*Almadi et al. Am J Gastro 2017
**Leggett et al. P & Photodynamic Rx 2012
Adjunctive intraductal ablation
 Intraductal ablation
• PDT: reactive oxygen species – tumor obliteration
• RFA: thermal energy – coagulative necrosis

• Data suggest increased survival with both

• No difference in survival between PDT and RFA in
a small retrospective study**
Dolak et al. UEGJ 2017
Figueroa-Barojas et al. J Oncol 2012
Dolak et al. Surg Endosc 2013
**Strand et al. GIE 2014
Current status
• Stronger evidence for hilar CCA
• Harder to perform
PDT •
•
Not widely available
Expensive
• Photosensitivity
• Recommended where available

• Data confounded by heterogeneity

RFA •
•
•
Easy to use
Widely available
Inexpensive
• Recommended
Thank you